WEST VIRGINIA FAMILY HEALTH PROVIDER MANUAL TABLE OF CONTENTS

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2 TABLE OF CONTENTS CHAPTER/UNIT TOPIC Quick Reference Introduction CHAPTER 1 MEMBER ENROLLMENT AND BENEFITS SEE PAGE 1.1 Enrollment and Eligibility Enrollment Process 10 Determination of Eligibility and Enrollment 10 Sample ID Cards 10 Verifying Eligibility 11 PCP Role in Determining Eligibility 13 Member Rights and Responsibilities West Virginia Family Health Benefits Medicaid Cost-Sharing 19 Mountain Health Trust Benefits Table 21 Mountain Health Bridge Benefits Table 24 Copay Prohibition 27 Dental Services Growing Up Program General Information 30 Service Delivery Requirements 30 Growing Up Outreach Unit 31 Claim Filing 31 Authorization 31 West Virginia Birth to Three 32 Required Screens and Tests 33 Detail of Screens and Services 35 Dental Services and Screening: Child Under Age Orthodontic Requirement & Prior Authorization: Child 35 Under Age 21 Dental Services: Adult Age 21 and Over 36 Dental Services Requiring Prior Authorization 37 Dental Service Retrospective Review 38 Dental Services in Hospital Setting or Ambulatory Surgical 38 Center Vision Testing 39 Hearing Screening 39 Developmental/Behavioral Appraisal 40 Anemia Screening 41 Blood Lead Level Screening 41 Immunizations 43 Vaccines for Children (VFC) Program 44 Immunization Registry 44 1 P age

3 CHAPTER 2 PROVIDER RESPONSILITIES SEE PAGE 2.1 PCP s Role General Information 46 PCP Patient Panel 46 Prospective Case Management 46 Addition of Newborns 47 Processing PCP Change Requests 47 Transfer of Medical Records 47 Appointment Standards 48 Immunizations 49 Vaccines For Children (VFC) Program 49 Immunization Registry 49 Oral Health Risk Assessment 50 Transfer of Non-Compliant Members 51 Coordination of Behavioral Health and Physical Health Services Specialty Care Practitioner Verifying Eligibility 54 Referrals Required for Specialty Care 56 Appointment Standards 57 Reimbursement 58 Emergency Services 59 Specialists Functioning as Primary Care Practitioners OB/GYN Services General Information 62 Member Self-Referral to OB/GYN 62 PCPs & Routine Gynecological Services 62 Referrals to Specialty Care Practitioners 62 Diagnostic Testing 62 Maternity Authorization 62 Newborns 63 Appointment Standards 64 Prenatal Risk Screening Instrument (PRSI) 65 Coding Maternity-Related Services 66 Family Planning Guidelines and Billing 68 Medicaid Sterilization/Hysterectomy Consent Forms 69 Abortion Services Hospital Services Inpatient Admissions 72 Hospital Transfer Policy 73 Outpatient Surgery Procedures 74 Emergency Room 75 Ambulance Services 77 Billing and Reimbursement 79 2 P age

4 CHAPTER 3 POLICIES AND PROCEDURES SEE PAGE 3.1 Practitioner Requirements and Guidelines General Information 81 West Virginia DHHR/BMS Policy Changes 81 Provider Manuals 81 Practitioner Education and Sanctioning 82 Practitioner Due Process 82 Title VI of the Civil Rights Act of Access and Interpreters for Members with Disabilities 82 Provider Termination 83 NaviNet 83 Credentialing Practices 84 Confidentiality 85 Fraud and Abuse 87 Environmental Assessment Standards 91 Reporting of Required Reportable Diseases 96 NCQA Compliance Requirements 98 Marketing Policies and Practices Claims and Billing Information Member Billing Policy 103 Excluded Providers or Credible Allegation of Provider Fraud 104 Claims Submission 105 Timely Filing 107 Prompt Pay 108 Payment Time Frames 108 BMS Reimbursement Hold Harmless 108 Electronic Claims Submission 109 Electronic Remittance Advance (ERA) 111 Claims Review 112 Administrative Claims Review 112 Medical Claims Review 113 Coordination of Benefits 114 Coordination of Benefits Policy 114 Specialty/Fee-For-Service Providers 115 Medicare 116 Nursing Care 117 Subrogation 117 Primary Care Services 119 Claim Coding Software 121 Billing 122 Early and Periodic Screening, Diagnostic, and Treatment 124 (EPSDT) Services EPSDT Claim Submission Time Frame 124 FQHC/RHC Billing Paper Format Requirements EDI Format Requirements 125 Obstetrical Care Services P age

5 Hospital Services 127 UB-04 Data Elements for Claims Submission 128 Sample UB-04 Claim Form Data Elements for Claims Submission 131 Sample 1500 Claim Form Reimbursement Introduction 135 Facility Providers 136 Physicians and Other Providers 138 Rate Changes 141 Directed Payments to Certain Qualified Providers Member and Provider Disputes Provider Appeals 145 Provider Disputes 147 Member Grievance Process 148 Informal Grievances 148 Formal Grievances 149 External Grievance Review 149 Member Appeals 150 Provider Initiated Member Grievances or Appeals 154 Provider Complaints 155 CHAPTER 4 HEALTH CARE MANAGEMENT SEE PAGE 4.1 Referrals General Information 157 Voice Activated Referral 159 Paper Referrals 163 Referrals for Specific Services 165 Out-of-Plan Referrals 165 Referrals for Second Opinions 165 Referrals for Surgical Second Opinions 165 Specialty Care Practitioners 165 Renal Dialysis Services 166 Audiology and Speech Therapy 166 Self-Referral Authorizations General Information 170 Criteria Used for Assessing Medical Appropriateness 170 Review/Determination of Medical Necessity 170 Utilization Management Contact Information 171 Services Requiring Authorization 172 Requesting an Authorization 173 Information Needed When Requesting an Authorization 173 Decision Time Frame 173 Expedited Authorization Requests 174 Medical Necessity Criteria 174 Post-Service Requests 175 Chiropractic Services P age

6 Durable Medical Equipment 177 Skilled Nursing Facility 179 Physical/Occupational/Speech Therapy 180 Rehabilitation Services 181 Extended Care in a Non-Hospital Facility 181 Cardiac and Pulmonary Rehabilitation Services 181 Home Health Care 182 Hospice Services 183 Pharmacy Services 184 New Technology Case Management Lifestyle Management Programs Overview 187 Maternity Program 188 Asthma Program 189 Diabetes Program 190 Cardiac Program 191 Chronic Obstructive Pulmonary Disease (COPD) Program 192 Special Needs Case Management 193 Complex Case Management 194 APPENDIX FORMS AND REFERENCE MATERIALS DIVA Quick Referral Entry Guide HealthCheck Health History Form 0-6 Years HealthCheck Health History Form 7-20 Years HealthCheck Program Periodicity Schedule Hysterectomy Acknowledgement Form Maternity Outcome Authorization Form Medical Record Review Member Outreach Form Physician Certification for Hysterectomy Physician Certification for Pregnancy Termination Prenatal Risk Screening Instrument (PRSI) Quick Reference Guide for Referrals and Authorization Referral Form Refund Form Sterilization Consent Form 5 P age

7 CALL TO INQUIRE ABOUT: QUICK REFERENCE TELEPHONE NUMBER HOURS OF OPERATION Behavioral Health Monday Friday 8:30 a.m. to 4:30 p.m. Case Management Monday Friday 8:30 a.m. to 4:30 p.m. Dental Provider Services (Claims Inquiries and Eligibility Verification) Digital Voice Assistant - DIVA (Eligibility Check/Generate and Review Referrals) Fraud and Abuse and Compliance Hotline Medical Management (Utilization Management) Monday Friday 8:30 a.m. to 4:30 p.m. (Central Time) hours a day/ 7 days a week hours a day/ 7 days a week Please do not leave multiple voic messages or call for the same authorization request on the same day. Monday Friday 8:30 a.m. to 4:30 p.m. (Voic during off hours. The call will be returned the next day.) Member Services Monday Friday 8 a.m. to 5 p.m. Provider Services (Claims Inquiries and Eligibility Verification) TTY/TDD Line 711 or Monday Friday 8:30 a.m. to 4:30 p.m. FAX NUMBER General: Prenatal Risk Forms & Member Outreach Forms: Hour Nurse Help Line WVFH(9834) 24 hours a day/ 7 days a week Please Note: After regular business hours, the Provider Services department line will be answered by an automated system that provides callers with operating hours information and instructions on how to verify enrollment for a member with an Urgent Condition or an Emergency Medical Condition. 6 P age

8 MAILING ADDRESSES West Virginia Family Health Claims Department P.O. Box Camp Hill, PA Emdeon & RelayHealth Electronic Claims Submission Payer ID: West Virginia Family Health Dental Claims Department P.O. Box 1597 Milwaukee, WI West Virginia Family Health Provider Correspondence Attn: Clinical Provider Appeals P.O. Box Pittsburgh, PA West Virginia Family Health Member Correspondence P.O. Box Pittsburgh, PA West Virginia Family Health Dental Authorizations Department P.O. Box 628 Milwaukee, WI West Virginia Family Health Dental Provider Correspondence and Appeals P.O. Box 1462 Milwaukee, WI West Virginia Family Health General Correspondence P.O. Box Camp Hill, PA West Virginia Family Health Checks P.O. Box Camp Hill, PA WEBSITE This provider manual along with various tools and reference materials are available at 7 P age

9 INTRODUCTION Highmark Blue Cross Blue Shield West Virginia ( Highmark West Virginia ) has contracted a network of providers to service the West Virginia Medicaid population for the West Virginia Family Health Plan, Inc. ( WVFH ). WVFH is a Provider Sponsored Network ( PSN ) organization composed of 26 shareholders, including 22 Federally Qualified Health Centers ( FQHCs ), two clinics, the Primary Care Association and Highmark West Virginia. WVFH is based in West Virginia and intends to operate as a Managed Care Organization ( MCO ) providing services to Medicaid beneficiaries. Hereinafter, WVFH may also be referred to as MCO. The PSN model offers many benefits and gives WVFH the ability to have a stronger focus on quality of care through care and disease management and address socio-economic issues as well as those unique issues to the low income population. Combining the hands on experience of providers with the industry expertise of Highmark West Virginia will ensure that this PSN will provide superior care. WVFH and Highmark West Virginia intend to collaboratively participate in the West Virginia Medicaid program to create a more effective care delivery system and improve the overall health of West Virginia Medicaid recipients. This combined ownership integrates the strengths of the provider community with a health insurance issuer that has a strong historical state-wide presence and leverages the strengths of both to create a new Medicaid MCO. This partnership provides an opportunity to create a healthcare delivery system designed to improve access to and quality of care for West Virginians, as well as promote healthier outcomes through medical home systems of care Highmark Inc. All rights reserved. Confidential Information DO NOT DUPLICATE except for West Virginia Medicaid managed care program review activities. This manual is exempt from disclosure pursuant to WV Uniform Trade Secrets Act et seq., and WV FOIA 29B-1-4(a). Information in this document is not generally known to individuals outside WVFH and has commercial value for WVFH s competitive advantage. Unauthorized use or disclosure constitutes misappropriation of a Trade Secret and harm to WVFH s competitive position, addressed through criminal and/or civil penalties to the disclosing party. Highmark Blue Cross Blue Shield West Virginia is an independent licensee of the Blue Cross and Blue Shield Association. 8 P age

10 CHAPTER 1: MEMBER ENROLLMENT AND BENEFITS UNIT 1: ENROLLMENT AND ELIGIBILITY IN THIS UNIT TOPIC SEE PAGE Enrollment Process 10 Determination of Eligibility and Enrollment 10 Sample ID Cards 10 Verifying Eligibility 11 PCP Role in Determining Eligibility 13 Member Rights and Responsibilities 14 9 P age

11 1.1 ENROLLMENT PROCESS Determination of eligibility and enrollment Mountain Health Trust is the name for West Virginia s Medicaid mandatory managed care program for Temporary Assistance for Needy Families (TANF) and TANF-related children and adults who are eligible to participate in managed care. West Virginia Health Bridge ( WVHB ) is West Virginia s mandatory managed care program for adults eligible for the Medicaid Alternative Benefit Plan (ABP) under Medicaid expansion through the Affordable Care Act (ACA). Under the West Virginia Mountain Health Trust Program and WVHB, the State determines eligibility, and enrollment is determined through Maximus, a broker hired by the State of West Virginia for enrollment services. Once the beneficiary selects West Virginia Family Health ( WVFH ), the plan is notified electronically of enrollment. At that time, a packet of information is sent along with their WVFH ID card. Sample ID cards Front: Mountain Health Trust Back: Front: Mountain Health Bridge Back: 10 P age

12 1.1 VERIFYING ELIGIBILITY Overview A West Virginia Family Health Member (WVFH) member will have two (2) cards: The WVFH ID card, as well as the West Virginia Medicaid card. Because of frequent changes in a member s eligibility, each Network practitioner is responsible to verify a member s eligibility with WVFH BEFORE providing services. Verifying a member s eligibility along with the applicable referral or authorization will assure proper reimbursement for services. Methods of verifying a member s eligibility To verify a member s eligibility, the following methods are available to all practitioners: 1. WVFH Identification Card The card itself does NOT guarantee that a person is currently enrolled in WVFH. Members are only issued an ID card once upon enrollment, unless the member changes their Primary Care Practitioner (PCP) or requests a new card. Members are NOT required to return their identification cards when they are no longer eligible for WVFH. 2. The WVFH Interactive Voice Response System (IVR) System Available 24 hours a day, seven days a week at To verify member eligibility at each visit, practitioners follow a few simple steps which are listed below. Verifying eligibility via the WVFH IVR System The WVFH IVR System can be accessed by calling Press 1 to verify eligibility VERIFICATION OF COVERAGE: Enter the members 8 digit identification number followed by #. Press # to start over Press # to return to main menu Press 0 zero) for assistance Continued on next page 11 P age

13 1.1 VERIFYING ELIGIBILITY, Continued Verifying eligibility via the WVFH IVR System (continued) VERIFICATION OF DATE QUESTION: Press 1 to verify coverage for TODAY or the PCP assigned to the member TODAY. Press 2 to verify coverage for a DIFFERENT day or the PCP assigned for a DIFFERENT day. Enter the date using the 2-digit month, 2-digit day, and 4-digit year. o Press 1 if the repeated date is correct. o Press 2 if the repeated date is incorrect. Press 1 for more information including spelling of member s name and PCP information. 12 P age

14 1.1 PCP ROLE IN DETERMINING ELIGIBILITY Practitioner panel list Primary care practitioners (PCPs) can verify eligibility by consulting their panel listing in order to confirm that the member is a part of the practitioner s panel. The panel list is distributed on or about the first of every month. The primary care practitioner should check the panel list each time a member is seen in the office. If a member s name is on the panel list, the member is eligible with WVFH for that month. If a patient is not on the practitioner s panel list If patients insist they are effective, but do not appear on the practitioner s panel list, the practitioner should call the WVFH Provider Services Department at for help in determining eligibility. 13 P age

15 1.1 MEMBER RIGHTS AND RESPONSIBILITIES Introduction As members of West Virginia Family Health (WVFH), patients have the following rights and responsibilities. Member Rights 1. Receive member rights and responsibilities and learn about them. 2. Get help you need to understand this book. 3. Receive information about us, our services, doctors, other providers. You should have access to services that are needed when services are accessible to you. 4. See your medical records (request and receive a copy within 30 days of request or have it amended within 60 days) 5. Have your medical records kept private. You must tell us in writing that it is OK for us to share them or it is allowed by law. 6. Receive complete facts from your doctor relating to your condition or treatment plan. 7. You can inspect and offer corrections to your own medical records, and request a copy of your records. 8. Be part of honest talks about your needs and treatment options. This is your right no matter the cost and whether your benefits cover them. Be part of decisions that are made about your health care needs. 9. Be told about other treatments or plans for care in a way that fits your condition. You can receive information about other courses of care in an understandable form 10. Get news about how doctors are paid. 11. Find out how we decide if new technology or treatment should be part of a benefit. 12. Be treated with respect, dignity and the right to privacy all the time. 13. Talk to your doctor about private things. 14. Have problems taken care of fast. This includes things you think are wrong like issues about your coverage, getting an approval from us, or payment of service. 15. Be treated the same as others. 16. Get care that should be done for medical reasons. We must furnish health care services specified in this contract. 17. Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. 18. Choose your PCP from our Provider Directory that is taking new patients. 19. Use providers who are in our network - choose from among those affiliated with WVFH. Continued on next page 14 P age

16 1.1 MEMBER RIGHTS AND RESPONSIBILITIES, Continued Member Rights (continued) 20. Get medical care in a timely manner. 21. Get services from providers outside our network in an emergency. 22. Be able to make choices about your care. You can participate in decisionmaking, including the right to refuse treatment or care from your PCP or other caregivers. 23. Be able to obtain a prompt resolution of issues raised. This includes complaints, grievances, or appeals and issues related to authorization, coverage, or payment of services. 24. Make an Advance Directive (also called a living will). 25. Tell us your concerns about WVFH and the services you get. 26. Question a decision we make about coverage for care you got from your doctor. 27. File a complaint or an appeal for any care you get or if your language needs are not met. 28. Ask how many grievances and appeals have been filed and why. 29. Tell us what you think about your rights and responsibilities. You can suggest changes. 30. Offer suggestions for changes in policies and procedures 31. Ask about our Quality Improvement Program. You can tell us how you would like to see changes made. 32. Ask about our utilization review process. You can give us ideas on how to change it. 33. Know that the date we use when you joined our health plan decide your benefits. 34. Know that we only cover services that are part of your plan. 35. Know that we can make changes to benefits as long as we tell you about the changes in writing. 36. Ask for this member handbook and other member materials in other formats at no charge to you. This includes other languages, large print, audio CD or Braille. 37. Ask for an oral interpreter and translation services in all non-english languages at no cost. You can call member services for assistance. This includes all languages of the major population groups served. 38. Use interpreters who are not your family members or friends. 39. Know you are not liable if your plan becomes bankrupt (insolvent). 40. Know your provider can challenge the denial of service with your approval. 41. Know you can request a copy of the member handbook at any time. You will be notified annually of your right to request a handbook. Continued on next page 15 P age

17 1.1 MEMBER RIGHTS AND RESPONSIBILITIES, Continued Member Rights (continued) 42. Know how you can get a list of providers in the network by calling member services. The list includes names, credentials, and education level of all network providers. You should know how you may choose providers within WVFH. You can call member services for assistance. 43. Know you are free to exercise your rights. Exercising these rights does not adversely affect the treatment of the member. 44. Receive information in accordance with contract standards. 45. Receive a second opinion at no cost to you for a medical condition. 46. Know that we, your doctors, and other providers cannot treat you in a different way because of your age, sex, race, national origin, language needs, or degree of illness or health condition. This includes your religion, mental or physical disability, sexual orientation, genetic information, and source of payment. Member Responsibilities As a member of WVFH, you also have some responsibilities: 1. Tell us, your doctors, and other health care providers what they need to know to treat you. 2. Learn as much as you can about your health issue and work with your doctor to set up treatment goals you agree on with your doctor. 3. Ask questions about any medical issue. Make sure you understand what your doctor tells you. 4. Follow the care plan and instructions that you have agreed on with your doctors or other health care professionals. 5. Do the things that keep you from getting sick. 6. Make and keep medical appointments. Tell your doctor at least 24 hours in advance when you cannot make it. 7. Always show your member ID card when you get services. 8. Use the emergency room only in cases of an emergency or as your doctor tells you. 9. If you owe a co pay to your hospital, PCPs, or pharmacies, pay at the time the services are received. 10. Tell us right away if you get a bill that you should not have gotten or if you have a complaint. 11. Treat all WVFH staff and doctors with respect and courtesy. 12. Know and follow the rules of your health plan. Continued on next page 16 P age

18 1.1 MEMBER RIGHTS AND RESPONSIBILITIES, Continued Member Responsibilities (continued) 13. Know that laws guide your health plan and the services you get. 14. Know that we do not take the place of workers compensation insurance. 15. Tell your DHHR caseworker and us when you change your address, family status or other health care coverage. 17 P age

19 CHAPTER 1: MEMBER ENROLLMENT AND BENEFITS UNIT 2: WEST VIRGINIA FAMILY HEALTH BENEFITS IN THIS UNIT TOPIC SEE PAGE Medicaid Cost-Sharing 19 Mountain Health Trust Benefits Table 21 Mountain Health Bridge Benefits Table 24 Copay Prohibition 27 Dental Services P age

20 1.2 MEDICAID COST-SHARING Overview Medicaid members will be required to pay for a portion of their care based on the member s family income. The Bureau of Medical Services (BMS) determines these copay amounts, and there are no premiums, deductibles, or other cost-sharing obligations for the member under the West Virginia Medicaid program. SERVICE Up to 50.0% % FPL 1 FPL % FPL 1 and above Inpatient Hospital $0 $35 $75 Office Visit (Physicians & Nurse Practitioner) $0 $2 $4 Non-Emergency Use of Emergency Department Hospital Only Any services received during a visit coded as non-emergent surgical procedures provided in a physician s office, ambulatory surgical center, or any other outpatient setting excluding emergency rooms. $8 $8 $8 $0 $2 $4 1 Federal Poverty Level Copays prohibited WVFH will not charge copays per BMS requirements for: Children under age 21 Pregnant women, including the 60 day period after the pregnancy ends American Indians and Alaska Natives Members receiving hospice care in a nursing home Dental services Emergency room services (for emergent use of hospital ER only) Continued on next page 19 P age

21 1.2 MEDICAID COST-SHARING, Continued No copays per BMS requirements (continued) Family planning services Members in a nursing home Members who meet household maximum limit for cost sharing obligations per calendar quarter Other limits may apply as provided by the state plan amendment 20 P age

22 1.2 MOUNTAIN HEALTH TRUST BENEFITS TABLE CHILDREN (0 up to 21 years) Inpatient Services (Note A, B, C, and D below) Inpatient Hospital Care Inpatient Rehabilitation Outpatient Services Diagnostic X-ray, laboratory services, and testing Physical Therapy Speech Therapy Occupational Therapy Ambulatory Surgery Center Services Clinic Services Genetic Testing Physician/NP/NMW/FQHC/RHC Services Primary/Preventive Care Visits Physician Office Visits Specialty Care Podiatry Cardiac and Pulmonary Rehabilitation Dental (General dentistry) Refer to page 56 in Scion Dental Provider Manual Home Health Durable Medical Equipment Orthotics & Prosthetics Family Planning Services & Supplies Hospice (In-home care) Ambulance (Emergency transportation) Chiropractic Services Tobacco Cessation Diabetes Management Private Duty Nursing Vision Hearing EPSDT (Well-child visits) ADULTS (21 years and older) Inpatient Services (Note A, B, C, and D below) Inpatient Hospital Care Outpatient Services Diagnostic X-ray, laboratory services, and testing Physical Therapy Speech Therapy Occupational Therapy Ambulatory Surgery Center Services Clinic Services Genetic Testing Physician/NP/NMW/FQHC/RHC Services Primary/Preventive Care Visits Physician Office Visits Specialty Care Podiatry Cardiac and Pulmonary Rehabilitation Dental Services (Emergent treatment only) Home Health Durable Medical Equipment Orthotics & Prosthetics Family Planning Services & Supplies Hospice (In-home care) Ambulance (Emergency transportation) Chiropractic Services Tobacco Cessation Diabetes Management Vision benefits are limited to medical treatment only Continued on next page 21 P age

23 1.2 MOUNTAIN HEALTH TRUST BENEFITS TABLE, Continued CHILDREN (0 up to 21 years) Behavioral Health Services Inpatient Psychiatric and Behavioral Health Stay Inpatient Chemical Dependency/Mental Health Stay Outpatient and Psychological Services Rehabilitation in Residential Treatment Inpatient Psychiatric Services ADULTS (21 years and older) Behavioral Health Services Inpatient Psychiatric and Behavioral Health Stay Inpatient Chemical Dependency/Mental Health Stay Outpatient and Psychological Services The services below are covered through Medicaid, but are not provided through your plan. For information, on how to use these services, look at section of the handbook that explains what Medicaid covers. Nursing Home Services Non-Emergency Transportation Nursing Home Services Non-Emergency Transportation (A) If the member is participating in a chronic care health home, the health home must be notified of any use of emergency services. They will be notified of any inpatient admission or discharge of a health home member that WVFH learns of through its inpatient admission initial authorization and concurrent review processes within 24 hours. (B) If the member is in an inpatient facility on the date of their enrollment with WVFH, the inpatient charges and the charges for a transfer facility will be paid by BMS. This includes charges billed while they are in the hospital, transferred to another hospital during their illness, or transferred inside the same hospital. WVFH will be responsible for all other covered services on or after the effective date. These charges include: a. Emergency transportation b. Doctor and other professional fees while you are at the hospital c. Outpatient care (C) WVFH is responsible for all charges during the inpatient newborn stay if newborn is born to a mother who is a current WVFH member until the newborn is discharged from the hospital. (D) WVFH is not responsible for inpatient charges for a member who is no longer eligible for Medicaid coverage as of the first of the month following the loss of Medicaid coverage. Nursing home services: The services are covered through Medicaid fee-for-service. Non-emergency transportation: MTM is available to provide non-emergency medical transport needs. MTM will schedule the request for transportation and send a ride to the member. MTM s Call Center is available Monday-Friday, 7 a.m. to 6 p.m., by calling for a reservation. If the member needs to follow up on a previously scheduled appointment, they can call the Where s My Ride hotline at (TTY ). Continued on next page 22 P age

24 1.2 MOUNTAIN HEALTH TRUST BENEFITS TABLE, Continued Chemical dependency/behavioral health services: Members do not need a referral for behavioral health services, including behavioral health care (depression) or drug and alcohol abuse. Birth to Three services: To be eligible for Birth to Three services, an infant or toddler under the age of three can either have a delay in one or more areas of their development, or be at risk of possibly having delays in the future. If you are interested in referring your child for services or would like more information, in West Virginia call or visit the Birth to Three website at Nursing Facility Services: Facility-based nursing services to those who require 24 hour nursing care are not covered. Weight management services are not a covered benefit except for bariatric surgery which is a covered benefit under the fee-for-service. 23 P age

25 1.2 MOUNTAIN HEALTH BRIDGE BENEFITS TABLE CHILDREN (0 up to 21 years) Inpatient Services (Note A,B, C and D below) Inpatient Hospital Care Inpatient Rehabilitation Outpatient Services Diagnostic X-ray, laboratory services, and testing Physical Therapy Speech Therapy Occupational Therapy Ambulatory Surgery Center Services Clinic Services Genetic Testing Physician/NP/NMW/FQHC/RHC Services Primary/Preventive Care Visits Physician Office Visits Specialty Care Podiatry Cardiac and Pulmonary Rehabilitation Dental Orthodontics Home Health Durable Medical Equipment Orthotics & Prosthetics Family Planning Services & Supplies Hospice (In-home care) Ambulance (Emergency transportation) Chiropractic Services Tobacco Cessation Diabetes Management Private Duty Nursing Vision Hearing ADULTS (21 years and older) Inpatient Services (Note A,B, C and D below) Inpatient Hospital Care Outpatient Services Diagnostic X-ray, laboratory services, and testing Physical Therapy Speech Therapy Occupational Therapy Ambulatory Surgery Center Services Clinic Services Genetic Testing Physician/NP/NMW/FQHC/RHC Services Primary/Preventive Care Visits Physician Office Visits Specialty Care Podiatry Cardiac and Pulmonary Rehabilitation Dental Services (Emergent Treatment) Home Health Durable Medical Equipment Orthotics & Prosthetics Family Planning Services & Supplies Hospice (In-home care) Ambulance (Emergency transportation) Chiropractic Services Tobacco Cessation Diabetes Management Continued on next page 24 P age

26 1.2 MOUNTAIN HEALTH BRIDGE BENEFITS TABLE, Continued CHILDREN (0 up to 21 years) Behavioral Health Services Inpatient Psychiatric and Behavioral Health Stay Inpatient Chemical Dependency/Mental Health Stay Outpatient and Psychological Services Rehabilitation in Residential Treatment ADULTS (21 years and older) Behavioral Health Services Inpatient Psychiatric and Behavioral Health Stay Inpatient Chemical Dependency/Mental Health Stay Outpatient and Psychological Services The services below are covered through Medicaid, but are not provided through your plan. For information on how to use these services, look at the section of the handbook that explains what Medicaid covers. Nursing Home Services Non-Emergency Transportation Nursing Home Services Non-Emergency Transportation (A) If the member is participating in a chronic care health home, the health home must be notified of any use of emergency services. They will be notified of any inpatient admission or discharge of a health home member that WVFH learns of through its inpatient admission initial authorization and concurrent review processes within 24 hours. (B) If the member is in an inpatient facility on the date of their enrollment with WVFH, the inpatient charges and the charges for a transfer facility will be paid by BMS. This includes charges billed while they are in the hospital, transferred to another hospital during their illness, or transferred inside the same hospital. WVFH will be responsible for all other covered services on or after the effective date. These charges include: a. Emergency transportation b. Doctor and other professional fees while you are at the hospital c. Outpatient care (C) WVFH is responsible for all charges during the inpatient newborn stay if newborn is born to a mother who is a current WVFH member until the newborn is discharged from the hospital. (D) WVFH is not responsible for inpatient charges for a member who is no longer eligible for Medicaid coverage as of the first of the month following the loss of Medicaid coverage. Nursing home services: The services are covered through Medicaid fee-for-service. Non-emergency transportation: MTM is available to provide non-emergency medical transport needs. MTM will schedule the request for transportation and send a ride to the member. MTM s Call Center is available Monday-Friday, 7 a.m. to 6 p.m., by calling for a reservation. If the member needs to follow up on a previously scheduled appointment, they can call the Where s My Ride hotline at (TTY ). Continued on next page 25 P age

27 1.2 MOUNTAIN HEALTH BRIDGE BENEFITS TABLE, Continued Chemical dependency/behavioral health services: Members do not need a referral for behavioral health services, including behavioral health care (depression) or drug and alcohol abuse. Nursing Facility Services: Facility-based nursing services to those who require 24 hour nursing care are not covered. Weight management services are not a covered benefit except for bariatric surgery which is a covered benefit under the fee-for-service. 26 P age

28 1.2 COPAY PROHIBITION Copays prohibited Providers may not charge copays to the following members or on the following services: Family planning services; Emergency services; Members under age 21; Pregnant women (including the 60-day postpartum period following the end of pregnancy); American Indians and Alaska Natives; Members receiving hospice care; Members in nursing homes; Any additional members or services excluded under the State Plan authority 1 ; or Dental services Emergency room services (for emergent use of hospital ER only) Members who have met their annual maximum limit for the cost-sharing obligations: Maximum limit based on five percent (5%) of quarterly household income per calendar quarter. Other limits may apply. 1 Services excluded under State Plan authority currently include Dental Services, Emergency Services, Family Planning, and services for provider-preventable conditions are excluded from the copays requirement. Members with the federal poverty level (FPL) under 50 percent (50%) are exempt from inpatient and professional office visit copays. Copays allowed Providers may charge copays for the following services: Inpatient and Outpatient services; Non-emergency use of the Emergency Department; Physician office visits including but not limited to a psychiatrist or a nurse practitioner; Caretaker relatives age 21 and up; Transitional Medicaid members age 21 and up; and Any other members identified by WVFH who are not specifically exempt. 27 P age

29 1.2 DENTAL SERVICES Dental services in partnership with Scion Dental WVFH permits members to have access to dental providers in the Scion Dental network. Our partnership is designed to deliver the highest quality oral health solutions to plan members. To locate a provider for your patient, please see the network provider listing through the website: Members should be advised to refer to their Member Handbook for additional information related to dental benefits, authorizations, and referrals related to dental services. 28 P age

30 CHAPTER 1: MEMBER ENROLLMENT AND BENEFITS UNIT 3: GROWING UP PROGRAM IN THIS UNIT TOPIC SEE PAGE General Information 30 Service Delivery Requirements 30 Growing Up Outreach Unit 31 Claim Filing 31 Authorization 31 West Virginia Birth to Three 32 Required Screens and Tests 33 Detail of Screens and Services 35 Dental Services and Screening: Child Under Age Orthodontic Requirement & Prior Authorization: Child 35 Under Age 21 Dental Services: Adult Age 21 and Over 36 Dental Services Requiring Prior Authorization 37 Dental Service Retrospective Review 38 Dental Services in Hospital Setting or Ambulatory 38 Surgical Center Vision Testing 39 Hearing Screening 39 Developmental/Behavioral Appraisal 40 Anemia Screening 41 Blood Lead Level Screening 41 Immunizations 43 Vaccines for Children (VFC) Program 44 Immunization Registry P age

31 1.3 GENERAL INFORMATION EPSDT overview West Virginia Family Health s (WVFH s) Growing Up Program is based upon the federally mandated Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program for Medical Assistance eligible children under the age of 21 years. Through the EPSDT Program, children are eligible to receive regular medical, dental, vision, and hearing screens to assure that they receive all medically necessary services, without regard to Medical Assistance covered services. Each Network PCP and primary care/specialist is responsible for providing the health screens for WVFH members, and reporting the results of the screens to WVFH, as well as communicating demographic information (e.g. telephone number, address, alternate address) with the WVFH Outreach staff to assist with scheduling, locating and addressing compliance issues. PCPs that treat children under the age of 21 that are unable to comply with the requirements of the EPSDT Program must make arrangements for EPSDT screens to be performed elsewhere by a WVFH Network provider. Alternative PCPs and specialists should forward a copy of the completed progress report to the PCP so it can be placed in the member s chart. Service delivery requirements PCPs are required to assure all children under the age of 21 have timely access to EPSDT services, and are responsible for assuring continued coordination of care for all members due to receive EPSDT services. Also, PCPs are to arrange for medically necessary follow-up care after a screen or an encounter. The required screens and tests are outlined later in this section. PCPs are required to follow this schedule to determine when the necessary screens and tests are to be performed. Members must receive, at a minimum, eight screens between the ages of birth and 18 months, and seventeen screens between 19 months and 21 years. When treating Supplemental Security Income ( SSI ) and SSI-related members under the age of 21, an initial assessment must be conducted at the first appointment. Written assessment must be discussed with the member s family or custodial agency, grievance or appeal rights must be presented by the PCP, and recommendations regarding case management must be documented. PCPs are responsible for ongoing coordination and monitoring of care provided by other practitioners. Continued on next page 30 P age

32 1.3 GENERAL INFORMATION, Continued Growing Up Outreach Unit WVFH s Growing Up Outreach Unit works collaboratively with the Case Managers in coordinating medically necessary services to members. Staff provides outreach via telephone or mail when required, to members who are under 21 to provide education and assistance with scheduling appointments, transportation, and other issues that prevent access to health care. WVFH Outreach staff is available to outreach to members identified by the primary care practitioner (PCP) offices who are delayed with screens and/or immunizations or who are non-adherent with appointments. The PCP is responsible for contacting new members identified on encounter lists as not adhering to EPSDT periodicity and immunization schedules. The Growing Up contact person is an EPSDT Outreach Representative who can be reached at , Option 3. Please complete and mail to WVFH the Member Outreach Form, also located in this manual s Appendix, for any member with abnormal findings, or who did not show up for his/her appointment, so WVFH may contact the member. Claim filing WVFH requires all EPSDT screens be billed on a 1500 or UB-04, or successor form. Codes for services must be included on the form. A description of the services will not be accepted. The practitioner s tax identification number must be included on the form to avoid problems with payment of services. WVFH does not apply coordination of benefits to EPSDT screens. Completed paper claim forms should be submitted within sixty (60) days of the date of service to permit timely member outreach. Claims will be accepted up to 365 days following the date of service; however, missing EPSDT screening claims cause unnecessary outreach to members and providers. Please refer to the manual s Chapter 3, Unit 2: Claims and Billing for additional information regarding submission of claims for EPSDT visits. Authorization If a member needs to be referred for specialty care as a result of an EPSDT screening, a standard WVFH referral must be issued by the primary care practitioner (PCP) to an applicable specialist. Hospital admissions and some outpatient surgical procedures require authorization from the Utilization Management Department. 31 P age

33 1.3 WEST VIRGINIA BIRTH TO THREE Overview Following an EPSDT screen, if a developmental delay is suspected and the child is not receiving services at the time of the screening, the PCP may refer the child (not over three years of age) to West Virginia Birth to Three. What is WV Birth to Three? West Virginia Birth to Three is a statewide system of services and supports for children under age three who have a delay in their development, or may be at risk of having a delay, and their family. The Department of Health and Human Resources, through the Bureau for Public Health and the Office of Maternal, Child and Family Health, WV Birth to Three, as the lead agency for Part C of the Individuals with Disabilities Education Act (IDEA), assures that family-centered community-based services are available to all eligible children and families. To refer a child to the West Virginia Birth to Three system in-state, you may call FOR MORE INFORMATION For more information regarding WV Birth to Three, visit their website at 32 P age

34 1.3 REQUIRED SCREENS AND TESTS HealthCheck Program Periodicity Schedule The required screens and testing are listed below. Refer to the HealthCheck Program Periodicity Schedule on the next page for frequency of testing and for further clarification. Note: The claim forms do not indicate findings from the clinical exam. It is the responsibility of the PCP to document these findings in the medical record. Individuals birth through 3 years 1. Record of a health history from parent or guardian. 2. Unclothed physical examination 3. Developmental appraisal (Denver Test or equivalent), psychosocial and behavioral assessment 4. Autism screening 5. Growth measurement 6. Assessment of hearing and vision 7. Metabolic screening PKU 8. Anemia screening hemoglobin and/or hematocrit 9. Blood lead screening 10. Urine screen for bacteria, sugar, albumin (age 2-6) 11. Sickle Cell test 12. Tuberculosis testing 13. Evaluation for cholesterol screening 14. Assessing and updating appropriate immunizations 15. Oral health screening 16. Nutritional assessment The initial EPSDT screen shall be the newborn physical examination in the hospital provided that the newborn physical examination contains all of the EPSDT screening components. Individuals 3 years through age Record of a health history from parent or guardian 2. Unclothed physical examination, including Tanner score and blood pressure 3. Developmental, psychosocial, and behavioral appraisal 4. Vision test 5. Hearing test 6. Dental examination 7. Malnutrition evaluation 8. Tuberculosis testing Continued on next page 33 P age

35 1.3 REQUIRED SCREENS AND TESTS, Continued Individuals 3 years through age 20 (continued) 9. Iron anemia-hemoglobin and hematocrit 10. Lead poisoning evaluation (mandatory until age 6) 11. Sickle Cell testing 12. Evaluation for cholesterol screening 13. Assessing and updating appropriate immunizations 14. Nutritional assessment 15. STD screening and pap smear FOR MORE INFORMATION For more information regarding the HealthCheck Program, visit the website at HealthCheck Program Periodicity Schedule Click here for a larger printable version. The larger version is also available in the Appendix of this manual. 34 P age

36 1.3 DETAIL OF SCREENS AND SERVICES Dental Services and Screening: Child under age 21 A dental assessment at every well-child visit, through observation, should be conducted. A referral to a dentist is required beginning at 6 months after the first tooth erupts or by 12 months of age. The child should see the dentist every six months. The dentist must check for the following and initiate treatment or refer as necessary: Caries Fillings Present Missing Teeth (permanent) Oral Infection Dental services include relief of pain and infections, restoration of teeth and maintenance of dental health. Although an oral health screening is a part of a wellchild exam, it does not substitute for referral to and examination by a dentist. Remember: West Virginia Medicaid covers all children's dental services (up to age 21) for cleanings and fillings without a referral. Orthodontic requirement & prior authorization: Child under age 21 WVFH has specific dental utilization criteria as well as a prior authorization to manage the utilization of services. Consequently, WVFH s operational focus is on assuring compliance with its dental utilization criteria. The contact phone number for Dental Provider Services (Claims Inquiries and Eligibility Verification) is Orthodontic documentation requirements include, but are not limited to: A treatment plan (Orthodontics) Six (6) diagnostic quality photos Panoramic or FMX X-ray Cephalometric X-ray Prior authorization request WV Medicaid Orthodontic Prior Authorization Form Please review the section of the West Virginia Medicaid Clinical Criteria for Prior Authorization of Treatment that outlines the clinical criteria for orthodontics. Reimbursement for children s orthodontic services covers the entire duration of treatment. Claims, dental/orthodontic authorization requests and supporting documents, and provider correspondence and appeals can be submitted to the following addresses: CLAIMS AUTHORIZATIONS CORRESPONDENCE & APPEALS West Virginia Family Health Dental Claims Department P.O. Box 1597 Milwaukee, WI West Virginia Family Health Dental Authorizations Department P.O. Box 628 Milwaukee, WI West Virginia Family Health Dental Provider Correspondence & Appeals P.O. Box 1462 Milwaukee, WI Continued on next page 35 P age

37 1.3 DETAIL OF SCREENS AND SERVICES, Continued Dental services: Adult age 21 and over The covered adult (age 21 and over) dental benefit is for urgent/emergent dental extractions. A referral from the PCP is not required for the initial evaluation by the dental provider. The dental provider needs preauthorization only if more than two (2) teeth are extracted or if IV sedation is requested. Panorex films will be requested for extraction of more than two (2) teeth. Examples of urgent/emergent dental services are: Dental caries with abscess Incision & Drainage (I&D) of abscess Repair of acute wounds Tooth broken off to the gum line Dental caries with pain Non-restorable tooth Non- Covered Services Dental services not covered by WVFH include, but are not limited to, the following. Non-covered services are not eligible for Department of Health and Human Resources hearing or desk/document review, and include: Experimental/investigational or services for research purposes Removal of primary teeth whose exfoliation is imminent Dental services for which PA has been denied or not obtained Dental services for the convenience of the member, the member s caretaker, or the provider of service Procedures for cosmetic purposes Temporomandibular Joint (TMJ) for adults Anesthesia services when solely for the convenience of the member, the member s caretaker, or the provider of service Local anesthesia and oral sedation are considered part of the treatment procedures and may not be billed separately Dental services for residents of Intermediate Care and Nursing Facilities i.e., Nursing Home, ICF/MR, and PRTF Dental services for participants enrolled in the Division of Rehabilitation Services or when services are covered under a Workers Compensation plan Dental services provided by providers not enrolled with WVFH Use of an unlisted code when a national CDT code is available Unbundled CDT codes Note: The extraction of impacted wisdom teeth is not a covered benefit, but wisdom teeth that are abscessed could meet the urgent/emergent guidelines. The claim must document that the services were urgent/emergent. Continued on next page 36 P age

38 1.3 DETAIL OF SCREENS AND SERVICES, Continued Dental services requiring prior authorization A decision will be made on a request for prior authorization within fourteen (14) calendar days from the date the request is received. If the request is denied for some or all of the services requested, the member and provider will be sent a written notice of the reasons for the denial(s) and the member will be advised that he or she may appeal the decision. WVFH has specific dental utilization criteria as well as a prior authorization and retrospective review process to manage the utilization of services. Consequently, the operational focus is on assuring compliance with its dental utilization criteria. One method used on a limited basis to assure compliance is to require providers to supply specified documentation prior to authorizing payment for certain procedures. Services that require prior authorization should not be started prior to the determination of coverage (approval or denial of the prior authorization) for non-emergency services. Non-emergency treatment started prior to the determination of coverage will be performed at the financial risk of the dental office. If coverage is denied, the treating dentist will be financially responsible and may not balance bill the Member, the State of West Virginia, and or any agents, and/or WVFH. Prior authorizations will be honored for 180 days from the date they are issued. An approval does not guarantee payment. The Member must be eligible at the time the services are provided. The provider should verify eligibility at the time of service. Requests for prior authorization should be sent with the appropriate documentation on an approved form. Any claims or Prior Authorizations submitted without the required documentation will be denied and must be resubmitted to obtain reimbursement. The basis for granting or denying approval shall be whether the item or service is medically necessary, whether a less expensive service would adequately meet the Member s needs, and whether the proposed item or service conforms to commonly accepted standards in the dental community. During the prior authorization process it may become necessary to have your patient clinically evaluated. If this is the case, you will be notified of a date and time for the examination. It is the responsibility of the participating dentist to ensure attendance at this appointment. Patient failure to keep an appointment will result in denial of the treatment. Continued on next page 37 P age

39 1.3 DETAIL OF SCREENS AND SERVICES, Continued Dental service retrospective review Services that would normally require Prior Authorization, but are performed in an emergency situation due to the following circumstances, will have a retrospective review: Retroactive Medicaid Eligibility Retrospective review is available for Medicaid members in instances where it is in the dental practitioner s opinion that a procedure may subject the member to unnecessary or duplicative service if delivery of the service is delayed until prior authorization is granted. Retrospective review needs to be submitted with the appropriate documentation by the provider within ten (10) business days of the date the service is performed. Types of documentation required, but not limited to, are: Radiographs (pre-op, post-op or opposing arch x-rays as indicated in the exhibits) Narrative of medical necessity Period charting Any claims for retrospective review submitted without the required documents will be denied and must be resubmitted for reimbursement. If the procedure(s) does not meet medical necessity criteria upon review by Utilization Management, the prior authorization request will be denied and the provider will not be reimbursed for the service by WVFH or the member. The Dental Consultants reviews the documentation to ensure the services rendered meet the clinical criteria requirements. Once the clinical review is completed, the claim is either paid or denied within twenty (20) calendar days for clean claims and notification will be sent to the provider via the provider remittance statement. Dental services in hospital setting or ASC Dentists can obtain prior approval for dental procedures performed in a hospital outpatient setting or an Ambulatory Surgical Center (ASC). Providers seeking information on this process can contact the Member Service Representative for specific details on how to obtain pre-authorization for services to be done in a hospital outpatient setting or an ASC. Continued on next page 38 P age

40 1.3 DETAIL OF SCREENS AND SERVICES, Continued Vision testing The chart should be affixed to a light-colored wall, with adequate lighting (10-30 foot candles) and no shadows. Ordinary room lighting typically does not provide adequate lighting and the chart will need a light of its own. The 20-foot line on the chart should be set at approximately the level of the eyes of a six-year-old. Placement of the child must be exactly 20 feet. Sites that do not have a 20-foot distance at which to test should obtain a 10-foot Snellen chart rather than convert the 20-foot chart. The eye not being tested must be covered with an opaque occluder; several commercial varieties are available at minimal cost, or the practitioner may improvise one, but the hand may not be used, as it leads to inaccuracies. In older children who seem to have difficulty or in young children, bring the child up to the chart (preferably before testing) and explain the procedure. For screening, the tester should start with the big E (20-foot line) and then proceed down rapidly line-by-line, as long as the child reads one letter per line, until the child cannot read. At this critical level, the child is tested on every letter on that line or adjacent line. Passing is reading a majority of letters in a line. It is not necessary to test for every letter on the chart. Tests for hyperopia may be done but are not required. Referral System Children seven (7) years of age and over must be referred if vision in either eye is 20/30 or worse. A child may be referred if the parent complains or if the doctor discovers a medical reason. (Generally, sitting close to the television without other complaints, and with normal acuity, is not a reason for referral.) Children failing a test for hyperopia may be referred. Children already wearing glasses must be tested with their glasses. If they pass, record the measurement; nothing further needs to be done. If they fail, refer for reevaluation to a WVFH Network specialist, preferably to the vision practitioner who prescribed the lenses, regardless of when they were prescribed. If the practitioner is unable to render an eye examination in a child nine years of age or older, because of the child s inability to read the chart or follow directions (e.g. a developmentally challenged child), refer this child to a Network ophthalmologist or optometrist. Hearing screening Sweep audiometry is the most frequently used examination and must be administered to every screened child within the first month of life, and after the age of three through a hearing test. Tuning forks and un-calibrated noisemakers are not acceptable for hearing testing. Continued on next page 39 P age

41 1.3 DETAIL OF SCREENS AND SERVICES, Continued Hearing screening (continued) For children under five years of age, observation should be made of the child s reaction to noises and to voices, unless the child is sufficiently cooperative to actually do the audiometry. For audiometry, explain the procedure to the child. For small children, present it as a game. Present one tone loud enough for the child to hear, and explain that when it is heard, the child should raise his/her hand and keep it raised until the sound disappears. Once the child understands, proceed with the test. Doing one ear at a time, set the decibel level at 25, and testing at 500 HZ. Then go successively to 1,000, 4,000, and 6,000. Repeat for the other ear. The quietest room at the site must be used for testing hearing. Referral System Any cooperative child failing sweep audiometry at any two frequencies must be referred. If a child fails one tone, retest that tone with threshold audiometry to be certain it is not a severe single loss. To be certain of the need for referral, the practitioner must immediately retest all failed tones by threshold audiometry, or, if there is question about the child s cooperation or ability at the time of testing, bring the child back for another sweep audiometry before referring. Please remember that audiometers must be periodically (at least annually) calibrated for accuracy. Developmental/ behavioral appraisal Since children with slow development and abnormal behavior may be able to be successfully treated if treatment is begun early, it is important to identify these problems as early as possible. Questions must be included in the history, which relate to behavior and social activity as well as development. Close observation is also needed during the entire visit for clues to deviations in those areas. If the practitioner suspects developmental delay he/she is required to refer the child to West Virginia Birth to Three at , for appropriate eligibility determination for early intervention services. Below Five Years of Age In addition to history and observation, a developmental evaluation is required. In children who are regular patients of the practitioner site, this may consist of ongoing recording in the child s chart of developmental milestones sufficient to make a judgment on developmental progress. In absence of this, the site may elect to conduct a Denver Developmental Screening Test as its evaluation utilizing the Denver II Form. Marked slowness in any area is cause for a referral to a Network specialist, e.g. developmental center, a MH/MR agency, a developmental specialist, a pediatric neurologist or a psychologist. If only moderate deficiencies in one or more areas are found, the practitioner must retest the child in days. Continued on next page 40 P age

42 1.3 DETAIL OF SCREENS AND SERVICES, Continued Developmental/ behavioral appraisal (continued) Social Activity/Behavior Questions should be asked to determine how the child relates to his family and peers and whether any noticeable deviation in any of his/her behavior exists. The DASE test may be used as an evaluation. Five Years and Older Since the usual developmental tests are not valid at this age, observation and history must be used to determine the child s normality in the areas listed below. Each child should be checked and recorded appropriately. Major difficulty in any one area, or minor difficulty in two or more areas, is cause for referral to a Network behavioral health professional for further diagnosis. 1. Social Activity/Behavior Does the child relate with family, teachers, and peers appropriately? Has the child had a change in behavioral, specifically a loss of interest in usual and preferred activities? 2. School Is the child s grade level appropriate for his/her age? Has the child been held back in school? Has the child demonstrated a decrease in academic work, social function, and/or sports? 3. Peer Relationships 4. Physical/Athletic Dexterity 5. Sexual Maturation Tanner Score. A full explanation of Tanner observations and scoring is found below. 6. Speech DASE Test. If there is a problem in this area, record accordingly, refer appropriately. Anemia screening A hemoglobin or hematocrit must be done at 12 months of age and for females once after the onset of menses. Subsequent testing should be at the practitioner s discretion, and based on the member s history and presenting complaints. Blood lead level screening All children must receive a screening blood lead test at 12 months and 24 months of age. Children between the ages of 36 months and 72 months of age must receive a screening blood lead test if they have not been previously screened for lead poisoning. Please refer to the HealthCheck Program Periodicity Schedule for further clarification. The Center for Disease Control requires the use of a blood lead test when screening children for lead poisoning. A blood lead screening should be done by a blood lead measurement of either a venous or capillary (finger stick) blood specimen. Continued on next page 41 P age

43 1.3 DETAIL OF SCREENS AND SERVICES, Continued Blood lead level screening (continued) Recommended Follow-Up Services For Children With Elevated Diagnostic* Blood Lead Levels: If the result is greater than or equal to 10mcg/dl, see if it was done by finger stick or venous puncture. If the screening test was a finger stick then a venous specimen for a confirmation needs completed (see following Table 1 for the recommended schedule for obtaining a confirmatory venous sample.) Table1: Recommended Schedule for Obtaining a confirmatory Venous Sample SCREENING TEST RESULT Perform a confirmation test (mcg/dl) within: week 1 month* Immediately as an emergency lab test *The higher the BLL on the screening test, the more urgent the need for confirmatory testing. WV CLPPP CASE MANAGEMENT PROTOCOL Time Frames for Environmental Investigation and Other Case Management Activities According to a Child s Blood Lead Level BLOOD LEAD LEVEL (mg/dl) ACTIONS TIME FRAME FOR BEGINNING INTERVENTION Within 30 days Provide caregiver lead education. Refer the child for social services if necessary. Make Priority Environmental. Referral for investigation and control current lead hazards Above actions, plus: Within 2 weeks If BLLs persist (i.e., 2 venous BLLs in this range at least 3 months apart) or increase, proceed according to actions for BLLS Make Priority Environmental. Referral for investigation and control current lead hazards Above actions, plus: Within 1 week Provide coordination of care (case management). Make Priority Environmental. Referral for investigation and control current lead hazards Above actions. Within 48 hours 70 or higher Above actions, plus hospitalize child for chelation therapy Within 24 hours immediately. Continued on next page 42 P age

44 1.3 DETAIL OF SCREENS AND SERVICES, Continued Blood lead level screening (continued) Environmental Investigation of Lead Environmental investigation as required by EPSDT and the 1991 Center for Disease Control Prevention of Lead Poisoning Guidelines and Abatement of Lead Sources are to be referred to the appropriate entity funded for this task. Contact the National Lead Information Center (NLIC) line at LEAD (5323). Use the WVFH Member Outreach Form, also found in this manual s Appendix, to notify WVFH s Growing Up Outreach staff of the need for follow-up. WVFH can also assist with issues regarding elevated blood lead levels or regarding noncompliance. If the screening indicates the need for the member to be referred to a specialist, a WVFH Referral Form must be completed. This form is also available in this manual s Appendix and in the Provider Forms and Reference Materials under Providers at Immunizations Both state and federal regulations require that immunizations be brought up to date during health screens and any other visits the child makes to the office. The importance of assessing the correct immunization status cannot be overly stressed. In all instances, the practitioner s records must show immunization history and documentation must include the date of the immunization, the signature of the person administering the immunization, and the name and lot number of the antigen. This will provide the necessary basis for further visits and immunizations. Healthcare Effectiveness Data and Information Set (HEDIS) also evaluates Human Papillomavirus Vaccine (HPV) for Female Adolescents. This measure will assess the percentage of 13-year-old females who had three doses of the HPV vaccine. The measure is designed to evaluate compliance with Centers for Disease Control and Prevention and Advisory Committee on Immunization Practices immunization guidelines. WVFH follows recommended childhood immunization schedules approved by the Centers for Disease Control and Prevention s (CDC) Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics, and the American Academy of Family Physicians. To facilitate distribution of the most current version of this schedule, it has been added to the WVFH s website. A paper copy is available upon request. For a paper copy, please contact the Provider Services Department at Continued on next page 43 P age

45 1.3 DETAIL OF SCREENS AND SERVICES, Continued Vaccines for Children (VFC) Program Children under 21 years of age receiving Medicaid are eligible for Vaccines For Children (VFC) Program. All PCPs will be reimbursed for the administration of any vaccine covered under the VFC Program when a claim is received with the appropriate immunization code. Any procedures for immunizations not covered under the VFC Program, but covered by WVFH, will be reimbursed fee-for-service. Immunization Registry The West Virginia Statewide Immunization Information System (WVSIIS) helps ensure that all West Virginia children, adolescents, and adults have current immunizations. These shots provide protection from diseases like measles, rotavirus, human papillomavirus, hepatitis, and pertussis (whooping cough). This system creates a confidential, computerized information system that keeps complete, up-to-date records that providers can access, resulting in higher immunization rates and better patient care. State law requires all providers to report all shots they administer to children under age 18 to WVSIIS within two weeks. Childhood and adolescent immunization reviews should be done at well-child visits as well as during urgent problem-oriented visits. For more information about this registry, please contact: 44 P age

46 CHAPTER 2: PROVIDER RESPONSIBILITIES UNIT 1: PCP S ROLE IN THIS UNIT TOPIC SEE PAGE General Information 46 PCP Patient Panel 46 Prospective Case Management 46 Addition of Newborns 47 Processing PCP Change Requests 47 Transfer of Medical Records 47 Appointment Standards 48 Immunizations 49 Vaccines For Children (VFC) Program 49 Immunization Registry 49 Oral Health Risk Assessment 50 Transfer of Non-Compliant Members 51 Coordination of Behavioral Health and Physical Health Services P age

47 2.1 GENERAL INFORMATION Introduction The definition of a primary care practitioner (PCP) is a specific practitioner, practitioner group or a certified registered nurse practitioner (CRNP) operating under the scope of his/her licensure, and who is responsible for supervising, prescribing, and providing primary care services; locating, coordinating, and monitoring other medical care and rehabilitative services and maintaining continuity of care on behalf of a Medicaid member. The PCP is responsible for the coordination of a member s health care needs and access to services provided by hospitals, specialty care practitioners, ancillary services and other health care services. Although members may obtain some health care services by self-referral, the majority of their health care services are obtained either directly from or upon referral by the PCP. With the exception of self-referred services, all of the member s care must be provided or referred by the PCP except in a true medical emergency when time does not permit a member to contact their PCP. To assure continuity and coordination of care, when a member self-refers for care, a report should be forwarded to the PCP. By focusing all of a member s medical decisions through the PCP, WVFH is able to provide comprehensive and high quality care in a cost-effective manner. Our goal is to work together with a dedicated group of practitioners to make a positive impact on the health of our Membership and truly make a difference. PCP Patient Panel Each member in a family has the freedom to choose any Network PCP, and a member may change to another primary care practitioner should a satisfactory patient-practitioner relationship not develop. A PCP agrees to accept a minimum number of WVFH members, as specified in the State Bureau of Medical Services (BMS) contract, to their patient panel at each authorized office location without regard to the health status or health care needs of such members and without regard to their status as a new or existing patient to that practice or location. The primary care practitioner (PCP) may, upon sixty (60) days prior written notice to West Virginia Family Health, state in writing that they do not wish to accept additional members. The written request excludes members already assigned to the PCP s practice, including applications in process. Prospective Case Management Through WVFH s model of Prospective Case Management, we emphasize the importance of extensive member outreach, community involvement, and physician practice engagement. We support the efforts of physician practices in delivering the highest quality of care to members. Continued on next page 46 P age

48 2.1 GENERAL INFORMATION, Continued Addition of newborns When a member selects WVFH, the member s effective date is usually the 1st of the month. When the member is a newborn, the member may be added any time of the month. Because newborn information is reported to WVFH retroactively, newborns will show up as a retroactive addition to the primary care practitioner s monthly panel listing. Newborns will be effective on their date of birth or the date the newborn was added to the member s grant. Processing PCP change requests When a member wishes to change his or her primary care practitioner (PCP), the change is processed under the following guidelines: When the request is received prior to the 25 th of the current month, the new effective date will be the first of the following month. For example, if a member s request is received on October 7 th, the member will be effective November 1 st with the new PCP. When the request is received on or after the 25 th of the current month, the new effective date will be the first of the subsequent month. For example, if a member s request is received on October 28 th, the member will be effective December 1 st with the new PCP. If the member requests to change his or her PCP immediately, an exception to the above guidelines can be made if the situation warrants. Transfer of medical records PCPs are required to transfer member medical records or copies of records to newly designated PCPs within ten (10) business days from receipt of the request from the West Virginia Bureau for Medical Services ( BMS ), its agent, the member or the member s new PCP, without charging the member. 47 P age

49 2.1 APPOINTMENT STANDARDS WVFH PCP appointment standards PCPs agree to meet WVFH s appointment standards as follows: STANDARD Wait time for an Emergent Appointment Wait time for Urgent Care appointment Wait time for Routine Appointments Wait time for a Health Assessment/General Physical Examinations, and First Examinations After-Hours Care Accessibility Wait time for first appointment with member who is Supplemental Security Income (SSI) or SSI-related consumer Wait time for initial prenatal visit (applies to PCPs who provide prenatal care) MEASUREMENT Immediately seen or referred to an emergency facility Within 48 hours Within 21 business days of request Within 3 weeks of enrollment Access to practitioner 24 hours/7 days a week. A live person, recording, or auto attendant will direct patients in the case of a true emergency to call 911 or go to the nearest Emergency Room. An on-call physician is available after-hours. Within forty-five (45) days of enrollment unless the member is already in active care with a PCP or specialist. Within fourteen (14) days of the member being identified as being pregnant. 48 P age

50 2.1 IMMUNIZATIONS Vaccines for Children (VFC) Program Children under 21 years of age receiving Medicaid are eligible for Vaccines For Children (VFC) Program. All PCPs will be reimbursed for the administration of any vaccine covered under the VFC Program when a claim is received with the appropriate immunization code. Any procedures for immunizations not covered under the VFC Program, but covered by WVFH, will be reimbursed fee-for-service. Immunization Registry The West Virginia Statewide Immunization Information System (WVSIIS) helps ensure that all West Virginia children, adolescents and adults have current immunizations. These shots provide protection from diseases like measles, rotavirus, human papillomavirus, hepatitis and pertussis (whooping cough). This system creates a confidential, computerized information system that keeps complete, up-to-date records that providers can access, resulting in higher immunization rates and better patient care. State law requires all providers to report all shots they administer to children under age 18 to WVSIIS within two weeks. Childhood and adolescent immunization reviews should be done at well-child visits as well as during urgent problem-oriented visits. The provider signs an enrollment packet, has training, and determines the access option best for his/her practice. Based on this, the provider can begin using WVSIIS. FOR MORE INFORMATION For more information about the Immunization Registry, please call the WVSIIS Help Desk at , or visit their website at: 49 P age

51 2.1 ORAL HEALTH RISK ASSESSMENT Topical fluoride varnish Tooth decay remains one of the most common childhood diseases and is also one of the most preventable. Primary Care Practitioners (PCPs) can help prevent tooth decay by providing topical fluoride varnish in the office for their WVFH Medicaid patients under the age of three. Training required WVFH reimburses primary care providers who have been certified through a faceto-face training for fluoride varnish application offered through the West Virginia University School of Dentistry for the application of fluoride varnish to children ages 6 months to 36 months (3 years) who are at high risk of developing dental caries. The application of the fluoride varnish should include communication with and counseling of the child s caregiver, including a referral to a dentist. To receive payment for this service, the provider must complete training through West Virginia University School of Dentistry. FOR MORE INFORMATION Please refer to this manual s Chapter 3, Unit 2: Claims and Billing Information for billing instructions. 50 P age

52 2.1 TRANSFER OF NON-COMPLIANT MEMBERS Policy PCPs agree (a) not to discriminate in the treatment of his/her patients, or in the quality of services delivered to WVFH members on the basis of race, sex, age, religion, place of residence, health status or source of payment; and (b) to observe, protect and promote the rights of members as patients. PCPs shall not seek to transfer a member from his/her practice based on the member s health status. However, a member whose behavior would preclude delivery of optimum medical care may be transferred from the practitioner s panel. WVFH s goal is to accomplish the uninterrupted transfer of care for a member who cannot maintain an effective relationship with a given practitioner. Additionally, in order to assist Network practitioners in the management of members who violate office policy in regard to scheduled appointments, WVFH has instituted the following Member No-Show Policy: WVFH will recognize the individual practitioner s written office policy in regard to scheduled appointments. Network practitioners are responsible for recording no-show appointments in the member s medical record. When a transfer is being conducted due to member no-show, the practitioner s notification should indicate that the practitioner wants to transfer the member to another PCP s practice. Written transfer requests required Should an incidence of inappropriate behavior or member non-compliance with no-show policies occur, and transfer of the member is desired, the practitioner must send a letter requesting that the member be removed from his/her panel including the member s name and WVFH ID Number, and, when applicable, state their no-show policy, and the member(s) who has (have) violated the policy to the Provider Services Department at: West Virginia Family Health Attention: Provider Services P.O. Box Pittsburgh, PA All written requests are forwarded to the Enrollment Department within 48 hours of receipt. The Enrollment Department notifies the original practitioner in writing when the transfer has been completed. If the member requests not to be transferred, the PCP will have the final determination regarding continuation of primary care services. PCPs are required to provide emergency care for any WVFH member dismissed from their practice until the member transfer has been completed. 51 P age

53 2.1 COORDINATION OF BEHAVIORAL HEALTH AND PHYSICAL HEALTH SERVICES Coordination requirements Behavioral health or drug and alcohol services are covered by WVFH, including emergency room services, home health care, and emergency transportation services. WVFH is responsible for all emergency transportation in an ambulance to an emergency room and to a behavioral health facility. Emergency services provided in general hospital emergency rooms are the responsibility of WVFH regardless of the diagnosis or services provided. The only exception is for emergency room evaluations for voluntary or involuntary commitments pursuant to the 1976 Mental Health Procedures Act (50 P.S. Section 7101, et. Seq.), which are the responsibility of the BH-MCO. Both primary care practitioners (PCPs) and behavioral health clinicians have the obligation to coordinate care of mutual patients in accordance with state and federal confidentiality laws and regulations. This includes, but is not limited to: obtaining appropriate releases to share clinical information; making referrals for social, vocational, education or human services when a need is identified through assessment; notifying each other of prescribed medications; and being available for consultation when necessary. Referrals are not necessary for members to receive the services of a behavioral health practitioner. Please refer to the Beacon Provider Manual for details 52 P age

54 CHAPTER 2: PROVIDER RESPONSIBILITIES UNIT 2: SPECIALTY CARE PRACTITIONER IN THIS UNIT TOPIC SEE PAGE Verifying Eligibility 54 Referrals Required for Specialty Care 56 Appointment Standards 57 Reimbursement 58 Emergency Services 59 Specialists Functioning as Primary Care Practitioners P age

55 2.2 VERIFYING ELIGIBILITY WVFH Provider Digital Voice Assistant (DIVA) Due to frequent changes in a member s eligibility, specialty care practitioners must verify eligibility prior to rendering services to assure reimbursement. This can be done by calling the West Virginia Family Health (WVFH) Provider Digital Voice Assistant (DIVA) system: Available 24 hours a day, seven days a week at Steps in verifying eligibility via WVFH DIVA To verify Enrollee eligibility at each visit, practitioners follow a few simple steps, which are listed below: TO VERIFY ENROLLEE ELIGIBILITY QUESTION: Press 1 to verify eligibility. Enrollee Identification Number? Press 1 to verify eligibility using the patient s social security number. When prompted, enter the patient s 9-digit social security number, and then press the # key. Press 2 to verify eligibility using the patient s WVFH Enrollee identification number. When prompted, enter the patient s 8-digit WVFH identification number. Press 3 to verify eligibility using the patient s West Virginia Medicaid recipient identification number. When prompted, enter the patient s West Virginia Medicaid recipient identification number. Press 0 to speak to a Provider Services Representative. Press 9 to repeat the menu. Verification of Date Question Press 1 to verify whether the patient is eligible TODAY or the PCP assigned to Enrollee TODAY Press 2 to verify whether the patient is eligible on a specific date. Enter the date using the 2-digit month, 2-digit day, and 4-digit year. o Press 1 if the repeated date is correct. o Press 2 if the repeated date is incorrect. o Press 9 to listen to the instructions again. Press 0 to speak to a Provider Services Representative. Continued on next page 54 P age

56 2.2 VERIFYING ELIGIBILITY, Continued Steps in verifying eligibility via WVFH DIVA (continued) ADDITIONAL INSTRUCTIONS QUESTION: Press 1 to receive additional information about the patient/enrollee (includes the spelling of the Enrollee s first and last name). Press 2 to receive the patient s PCP name and telephone number (includes the spelling of the provider s name and phone number). Press 3 to fax information regarding the patient whose eligibility is being verified. You will be asked to enter the fax number for which you wish to receive the eligibility verification. Press 4 to verify eligibility for another patient/enrollee. Press 5 to exit. Press 6 to return to the menu of automated services. Press 9 to listen to the instructions again. Press 0 to speak to a Provider Services Representative. 55 P age

57 2.2 REFERRALS REQUIRED FOR SPECIALTY CARE PCP referral requirements All WVFH members must obtain a valid referral from their primary care practitioner (PCP) prior to receiving specialty services except for the services that can be accessed by a self-referral. Neonatologist exception The only exception to this is for Neonatologists who may issue a referral to other Network hospitals and/or specialists for babies discharged from the NICU who require service before seeing their PCP. Referrals should be issued under the baby s ID number. If the baby does not have an ID number, the practitioner should call WVFH s Utilization Management Department for authorization. Verifying PCP referrals via telephone WVFH members receive specialty care services from Network practitioners through a telephonic referral issued by the primary care practitioner (PCP) office. WVFH s IVR may be used by PCPs and OB/GYN practitioners to issue a referral, or by specialty care practitioners to verify the existence of a valid referral by calling If additional specialty care is needed If additional specialty care not authorized on the original referral is needed, please contact the member s PCP to obtain another WVFH referral. However, if the procedures are being performed on the same date of service and in the same office as indicated on the original referral, another referral is not necessary. The specialist is responsible for providing written correspondence to the member s PCP for coordination and continuity of care. Is visit an EPSDT referral? Providers must make reasonable efforts for every member under 21 years of age to determine whether a visit to the provider s office stems from an EPSDT referral by asking the referring provider, clinic, or member. If the visit is the result of an EPSDT screening, the appropriate space on the claim must be marked "yes" to indicate a referral was the source of the visit. Likewise, the appropriate space on the claim must be marked no if the information cannot be obtained or is not the result of a screening. 56 P age

58 2.2 APPOINTMENT STANDARDS Specialty care appointment standards Specialty care practitioners agree to meet WVFH s appointment standards, as follows: PRACTITIONER TYPE REQUIREMENT STANDARD Specialist Wait time for an emergent Immediately seen or referred to an appointment emergency facility Specialist Specialist Wait time for an Urgent Care appointment Wait time for Routine Appointments Within 48 hours Within 21 business days 57 P age

59 2.2 REIMBURSEMENT Payment Payment by WVFH is considered payment in full. Members will be held harmless for the costs of all Medicaid-covered services provided except for applicable cost-sharing obligations. Member Billing Policy Under no circumstance including, but not limited to, non-payment by WVFH for approved services, may a provider bill, charge, collect a deposit from, seek compensation, remuneration, or reimbursement from or have any recourse against a WVFH member beyond the rates established by the state-wide copayment schedule noted in this manual s Chapter 1, Unit 2 (page 2) and subject to the copay prohibitions also detailed in Chapter 1, Unit 2 (page 5). Non-covered services Practitioners may directly bill Members for non-covered services; provided, however, that prior to the provision of such non-covered services, the practitioner must inform the Member: (i) of the service(s) to be provided; (ii) that WVFH will not pay for or be liable for said services; (iii) of the Member s rights to appeal an adverse coverage decision as fully set forth in the Provider Manual; and (iv) absent a successful appeal, that Member will be financially liable for such services. FOR MORE INFORMATION Refer to this manual s Chapter 3, Unit 2: Claims and Billing for additional information regarding submission of claims. 58 P age

60 2.2 EMERGENCY SERVICES Notification requirements if directing a member to ER All WVFH members are informed that they must contact their PCP for authorization prior to seeking treatment for non-life or limb threatening conditions in an emergency room. However, WVFH realizes that there are situations when a member is under the care of a specialty care practitioner for a specific condition, such as an OB/GYN during pregnancy, and the member may contact the specialist for instructions. If a specialty care practitioner directs a member to an emergency room for treatment, the specialty care practitioner is required to immediately notify the hospital emergency room of the pending arrival of the patient for emergency services. The specialty care practitioner is required to notify the PCP of the emergency services within one (1) business day when the emergency room visit occurs over a weekend. Every effort should be made to direct members to WVFH Network hospitals. Chronic care health home notification If the member is participating in a chronic care health home, the health home must be notified of any use of emergency services and be notified of any inpatient admission or discharge of a health home member that the MCO learns of through its inpatient admission initial authorization and concurrent review processes within 24 hours. Emergency medical screening exam requirements A medical screening examination needed to diagnose a member s emergency medical condition must be provided in a hospital-based emergency department that meets the requirements of the Emergency Medical Treatment and Active Labor Act (EMTALA)(42 CFR , and (b) & (c)). WVFH will reimburse both the physician s services and the hospital s emergency services, including the emergency room and its ancillary services. 59 P age

61 2.2 SPECIALISTS FUNCTIONING AS PRIMARY CARE PRACTITIONERS WVFH approval required Specialists may function as a PCP for specific members with complex illnesses or conditions. In order for a specialist to function as a PCP, the specialist must be approved by the WVFH Medical Director. 60 P age

62 CHAPTER 2: PROVIDER RESPONSIBILITIES UNIT 3: OB/GYN SERVICES IN THIS UNIT TOPIC SEE PAGE General Information 62 Member Self-Referral to OB/GYN 62 PCPs & Routine Gynecological Services 62 Referrals to Specialty Care Practitioners 62 Diagnostic Testing 62 Maternity Authorization 62 Newborns 63 Appointment Standards 64 Prenatal Risk Screening Instrument (PRSI) 65 Coding Maternity-Related Services 66 Family Planning Guidelines and Billing 68 Medicaid Sterilization/Hysterectomy Consent Forms 69 Abortion Services P age

63 2.3 GENERAL INFORMATION Member self-referral to OB/GYN To eliminate any perceived barrier to accessing obstetrical/gynecological ( OB/GYN ) services, West Virginia Family Health ( WVFH ) allows all female members to self-refer to any Network OB/GYN for any OB/GYN related condition, not just for an annual exam or suspected pregnancy. When a member self-refers to the OB/GYN, the OB/GYN s office is required to verify eligibility of the member. WVFH members may also self-refer for family planning services. PCPs & routine gynecological services WVFH permits its primary care practitioners (PCPs) to perform routine gynecological exams and pap tests and provide care during pregnancy if they are so trained and equipped in their office. PCPs that provide obstetrical services must bill in accordance with WVFH guidelines and may only provide obstetrical services to those patients assigned to their panel. Referrals to specialty care practitioners If an OB/GYN determines that assessment or treatment by another specialty care practitioner is necessary, the OB/GYN is required to contact the member s primary care practitioner (PCP) to request a referral to a specialist. The OB/GYN practitioner is responsible for providing written correspondence to the member s PCP for coordination and continuity of care. The OB/GYN cannot refer a member directly to another specialty care practitioner with the exception of Network Perinatologists. Diagnostic testing Fetal non-stress tests and obstetrical ultrasounds can be performed in the OB/GYN s office or at a hospital without an authorization or a referral from WVFH. A referral is not required for mammograms or other testing or procedures performed at a Network hospital. Only a prescription is needed. Maternity authorization In addition to the authorization procedure for inpatient admissions found in this manual s Chapter 2, Unit 4: Hospital Services, WVFH requires the provider to complete a Maternity Outcome Authorization Form, found under Provider Forms and Reference Materials at within two (2) business days of the delivery. The receipt of this form lets WVFH know the mother has delivered, as well as alerting us that the baby was born and needs to be added to the system. This form can also be found in this manual s Appendix, as well as on the WVFH website at Continued on next page 62 P age

64 2.3 GENERAL INFORMATION, Continued Newborns Newborns of WVFH mothers will be covered for services rendered during the neonatal period. All charges for newborns that become enrolled in the plan, other than hospital bills covering the confinement for both mom and baby, are processed under the newborn name and newborn WVFH Identification Number. WVFH is responsible for all charges during the inpatient newborn stay if such newborn is born to a mother who is a current WVFH member until the newborn s discharge. 63 P age

65 2.3 APPOINTMENT STANDARDS OB/GYN standards Appointment standards for OB/GYN practitioners are as follows: REQUIREMENT Wait time for initial prenatal visit High-risk pregnancies STANDARD Within fourteen (14) days of the member being identified as being pregnant. 1 st Trimester within 14 days 2 nd Trimester within 7 days 3 rd Trimester within 3 days Within twenty-four (24) hours of identification of high-risk by WVFH or the maternity care provider, or immediately if an emergency exists. Standards for all specialists Additional standards apply to all specialists, including OB/GYNs: PRACTITIONER TYPE REQUIREMENT STANDARD Specialist Wait time for an emergent Immediately seen or referred to an appointment emergency facility Specialist Specialist Wait time for an Urgent Care appointment Wait time for Routine Appointments Within 48 hours Within 21 business days 64 P age

66 2.3 PRENATAL RISK SCREENING INSTRUMENT (PRSI) PRSI Form requirements The first visit with an obstetrical patient is considered to be the intake visit, or if a patient becomes a WVFH member during the course of her pregnancy, her first visit as a WVFH member is considered to be her intake visit. At the intake visit, a West Virginia Prenatal Risk Screening Instrument Form, found under Provider Forms and Reference Materials at (Form Number: WVDHHR/BPH/OMCFH/DPWH PRSI 04/27/2012) should be immediately faxed to WVFH s Maternity Case Management at or ed to WVFH via WVFH s secure portal and then filed in the member s medical record. This statewide form is available in this manual s Appendix and also at: The WV Prenatal Risk Screening Instrument (PRSI) should be updated at the week visits and also at the post-partum visit. These two updates should also be faxed to WVFH immediately following completion. Purpose of the PRSI Form The purpose of the PRSI Form is to help identify risk factors early in the pregnancy and engage the woman in case management. For that reason, the PRSI Form must be faxed to WVFH s Maternity Case Management department at within 2-5 business days of the intake visit. PRSI required for intake visit claim The PRSI Form is not a claim. However, the PRSI Form must be received by WVFH in order to process the claim for the intake visit. Please submit claims within 365 days to receive payment for the intake package. 65 P age

67 2.3 CODING MATERNITY-RELATED SERVICES Prenatal visits West Virginia Medicaid will not reimburse for global maternity-related procedure codes or bundled services codes because Medicaid members often change physicians or managed care entities during maternity care, which greatly complicates or precludes the use of global codes to pay for maternity care. Under the per visit reimbursement structure, the following procedure codes should be used when billing WVFH: all prenatal visits and dates of service must be included on the claim form and identified with Evaluation and Management code ( ) ONLY. The TH modifier must follow the code in the first position on the claim form. Delivery Delivery charges must be identified with CPT codes. Initial Prenatal Visit Incentive WVFH will reimburse providers a bonus payment of $200 for initial prenatal risk assessment visits rendered within the first trimester. Please bill as indicated below to receive the bonus payment: The initial prenatal visit MUST be rendered within the first trimester and the West Virginia Prenatal Risk Screening Instrument Form, found under Provider Forms and Reference Materials at must be completed during the visit and faxed to WVFH s Maternity Case Management department at within 2-5 business days of the visit. Procedure code T1001-HD (Initial Risk Assessment) must be reported on the same claim form as the maternity visit (99213-TH or T1015-TH) together on the same claim form to allow the bonus payment. The bonus payment will not be paid if both codes/modifiers referenced above are not reported on the same claim. The PRSI Form is not a claim form; however, the form must be received by WVFH and documented in our claims system prior to receipt of the claim to allow the appropriate bonus and intake visit payment. The initial prenatal visit MUST be rendered within the first trimester and the PRSI must be completed during the visit and faxed to WVFH s Maternity Case Management department at within 2-5 business days of the visit. Continued on next page 66 P age

68 2.3 CODING MATERNITY-RELATED SERVICES, Continued If first visit is not within the first trimester If the member s first prenatal visit doesn t occur within the first trimester then code HD should not be billed. However, the first visit with an obstetrical patient is considered to be the intake visit. If a patient becomes a WVFH member during the course of her pregnancy, her first visit as a WVFH member is considered to be her intake visit. At the intake visit, a PRSI Form must be completed and a claim submitted with code T1001-U9 for reimbursement. Billing instructions Billing instructions for Federally Qualified Health Centers (FQHCs)/Rural Health Centers (RHCs): If the PRSI was completed in the first trimester, report the services as follows: T Contracted rate or rate normally billed; T1001-U9 (Initial Risk Assessment) -- $200.00; and HD -- $0.00 If the PRSI was not completed within the first trimester, bill as follows: T1015 charge should be encounter rate or rate normally billed; and T1001-U9 -- $ (NO PAYMENT WILL BE MADE incentive is only reimbursed within the first trimester) Billing instructions for professional providers other than FQHCs/RHCs: If the PRSI was completed in the first trimester, report the services as follows: only with the provider s charge. The TH modifier must follow the code in the first position on the claim form; T1001-HD (Initial Risk Assessment) -- $200.00; and HD -- $0.00 If the PRSI was not completed within the first trimester, bill as follows: TH provider s charge; and T1001-U9 -- $ (NO PAYMENT WILL BE MADE - incentive is only reimbursed within the first trimester) 67 P age

69 2.3 FAMILY PLANNING GUIDELINES AND BILLING Guidelines WVFH permits Enrollees to see any Network or non-network practitioner for Family Planning Services only. Non-network providers are asked to educate members about the release of necessary medical data to WVFH. If a WVFH patient presents for family planning benefits, practitioners need to be aware of the following: The patient s eligibility can be verified by calling Family planning patients DO NOT need a referral from their PCP under federal mandate. A family planning patient may self-refer to her OB/GYN for prenatal care if she becomes pregnant. Billing When billing for family planning services, use the national standard codes. The FP modifier must follow the code in the first position on the claim form. When billing for contraceptives and family planning drugs for West Virginia Family Health members, use the appropriate J code. When a valid J code is not available, bill with an unspecified J code along with the NDC code and the number of units administered. 68 P age

70 2.3 MEDICAID STERILIZATION/HYSTERECTOMY CONSENT FORMS Surgical consent forms required for hysterectomy and voluntary sterilizations WVFH requires authorization for hysterectomies and voluntary sterilizations. WVFH, in accordance with the West Virginia Medicaid guidelines, will continue to require the completion of the State surgical consent forms for hysterectomies and sterilizations: Hysterectomy Acknowledgement Form Sterilization Consent Form These forms can be found under Provider Forms and Reference Materials at Copies of these forms are also available in this manual s Appendix. The surgical consent forms (DHS-2510-ENG (11/93)) for voluntary sterilizations must be completed and signed by the Enrollee thirty (30) days prior to the surgery. The consent form is valid for 180 days. Any provider requesting authorization for a sterilization must submit the signed consent form at least seven (7) days prior to the scheduled procedure. Urgent or retrospective authorizations Urgent authorizations or retrospective authorizations can be made upon request for sterilizations performed commensurate with a premature delivery or emergency abdominal surgery. The same responsibilities for member and providers still apply regarding completion of consent forms. 69 P age

71 2.3 ABORTION SERVICES Pregnancy termination policy and requirements West Virginia Medicaid covers pregnancy termination when the attending physician determines, in consultation with the member, that termination is medically advisable. Before making the determination, the physician must discuss the possible pregnancy termination with the member in light of her age, physical, emotional, psychological, and familial circumstances relevant to the well-being of the patient. Certification by the physician is required for payment. The provider office must submit the Physician Certification for Pregnancy Termination Form to WVFH s Utilization Management department by fax at at least one hour before the procedure, unless an emergency prevents prior submission of the form. The completed and signed form must accompany all claim forms for pregnancy terminations. This form is available in this manual s Appendix and can also be accessed through the West Virginia Medicaid website at Reimbursement WVFH cannot reimburse Medicaid providers for the services provided to Mountain Health Trust or Mountain Health Bridge members under any reported and verified abortion CPT codes. Abortion Services will be reimbursed under Fee-For-Service Medicaid. 70 P age

72 CHAPTER 2: PROVIDER RESPONSIBILITIES UNIT 4: HOSPITAL SERVICES IN THIS UNIT TOPIC SEE PAGE Inpatient Admissions 72 Hospital Transfer Policy 73 Outpatient Surgery Procedures 74 Emergency Room 75 Ambulance Services 77 Billing and Reimbursement P age

73 2.4 INPATIENT ADMISSIONS Authorization required for all inpatient admissions In order for West Virginia Family Health (WVFH) to monitor the quality of care and utilization of services by our members, all WVFH practitioners are required to obtain an authorization number for all hospital admissions and certain outpatient surgical procedures by contacting WVFH s Utilization Management Department at WVFH will accept the PCP, ordering practitioner, or the attending practitioner s request for an authorization of non-emergency hospital care; however, no party should assume the other has obtained authorization. WVFH will also accept a call from the hospital s Utilization Review Department. The Utilization Management Representative refers to the WVFH Medical Director if criteria or established guidelines are not met for medical necessity. The ordering practitioner is offered a peer review opportunity with the WVFH Medical Director for all potential denial determinations. 72 P age

74 2.4 HOSPITAL TRANSFER POLICY Transfer policy When a WVFH member requires hospitalization, WVFH s policy is to have the service rendered in a WVFH Network hospital. However, WVFH recognizes that it may not be possible to follow this general policy when a member presents to the closest medical facility due to a medical emergency. When the medical condition of the member requires an admission to a non-network hospital, the member will be transferred within twenty-four (24) hours of stabilization, when appropriate. In order to determine that the member is medically stable for transfer the WVFH Utilization Management staff will concurrently monitor the condition of the patient by communicating with the hospital s Utilization Review staff and the attending practitioner. WVFH will coordinate all necessary transportation for the timely transfer of the member. 73 P age

75 2.4 OUTPATIENT SURGERY PROCEDURES Verify if authorization is required Network practitioners may utilize a hospital s Short Procedure Unit (SPU) or Ambulatory Surgery Unit (ASU) for any authorized medically necessary procedure. Medical Necessity Reviews may be required for certain procedures. Please call WVFH s Utilization Management Department to verify if authorization is required or refer to the Administrative References on WVFH s website. Should a request to perform an outpatient procedure be denied by WVFH, the practitioner will issue written notification to the member and requesting provider. Urgent requests are responded to immediately. Due to monthly changes in member eligibility, WVFH recommends that authorization be requested at least two (2) working days in advance when possible. 74 P age

76 2.4 EMERGENCY ROOM Definition of emergency An emergency is defined as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: (a) placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; (b) serious impairment to bodily functions; or (c) serious dysfunction of any bodily organ or part. In all instances, when a member presents to an emergency room for diagnosis and treatment of an illness or injury, the hospital s pre-established guidelines allow for the triage of illness and injury. Conditions requiring emergency treatment The following conditions are examples of those most likely to require emergency treatment: Danger of losing life or limb Poisoning Chest pain and heart attack Overdose of medicine or drug Choking Heavy bleeding Car accidents Possible broken bones Loss of speech Paralysis Breathing problems Seizures Criminal attack (mugging or rape) Heart attack Blackouts Vomiting blood Dental traumatic injury Relief of severe dental pain Nonemergency services For applicable non-emergency services, a copay should be required from the member. WVFH members have been informed, through the Member Handbook, of general instances when emergency care is typically not needed. These are as follows: Cold Rash Sore throat Bruises Small cuts and burns Swelling Ear ache Cramps Vomiting Cough Continued on next page 75 P age

77 2.4 EMERGENCY ROOM, Continued Follow-up care All follow-up care after an emergency room visit must be coordinated through the primary care practitioner (PCP). Members are informed via the Member Handbook to contact their PCP for a referral for follow-up care in instances such as: Removal of stitches Changing of bandages Cast check Further testing Emergencies are handled in the same manner whether in or out of the WVFH service area. WVFH requests that Network practitioners inform WVFH by calling WVFH s Utilization Management Department whenever they learn that a member has received care outside of the service area. 76 P age

78 2.4 AMBULANCE SERVICES Emergent ambulance transportation Emergent transportation (911), including air ambulance, does not require authorization by WVFH. WVFH considers emergent transportation as transportation that allows immediate access to medical or behavioral health care and without such access could precipitate a medical or a behavioral health crisis for the patient. Either a Network or non-network ambulance provider may render 911 transportation without an authorization from WVFH. WVFH also considers the following situations emergent, and thus does not require authorization: ER-ER ER-to-Acute Care or Behavioral Health Facility Acute Cat-to-Acute Care or Behavioral health Facility Hospital-to-Hospital, when patient is being discharged from one hospital and being admitted to another. Providers should bill the above types of transports with the appropriate emergency, basic life support code and the modifier HH. Non-emergent ambulance transportation Authorization for non-emergent ambulance transportation is required by WVFH s Utilization Management Department. WVFH considers non-emergent transportation as transportation for a patient that does not require immediate access to medical or behavioral healthcare and/or if not provided would not result in a medical or a behavioral health crisis as non-emergent. Non-emergent transportation may include the following scenarios: Ambulance transports from one facility to another when the member is expected to remain at the receiving facility, which may include the following: Hospital to Skilled Nursing Facility (SNF) SNF to Hospital (non-emergent) Hospital to Rehabilitation Facility Rehabilitation Facility to Hospital (non-emergent) Ambulance transport to home upon discharge (if medically necessary and approved by WVFH) A WVFH Network ambulance provider should be contacted to render nonemergent transportation when possible. Continued on next page 77 P age

79 2.4 AMBULANCE SERVICES, Continued Facility to facility for diagnostic testing Ambulance transportation from one facility to another for diagnostic testing or services not available at the current facility, with the expectation of the member returning to the original facility upon completion of service, is the responsibility of the originating facility and does not require an authorization from WVFH. The originating facility should assume the cost for this type of transport even if for unforeseen circumstances, the member remains at the receiving facility. The originating facility may contact any ambulance service of their choosing to provide transport in this scenario only. Wheelchair van transport All wheelchair van transportation requires an authorization from WVFH s Utilization Management Department. 78 P age

80 2.4 BILLING AND REIMBURSEMENT Claims and reimbursement information Please see this manual s Chapter 3, Unit 2: Claims and Billing Information for information regarding claims submission, and Chapter 3, Unit 3: Reimbursement for information regarding reimbursement. 79 P age

81 CHAPTER 3: POLICIES AND PROCEDURES UNIT 1: PRACTITIONER REQUIREMENTS AND GUIDELINES IN THIS UNIT TOPIC SEE PAGE General Information 81 West Virginia DHHR/BMS Policy Changes 81 Provider Manuals 81 Practitioner Education and Sanctioning 82 Practitioner Due Process 82 Title VI of the Civil Rights Act of Access and Interpreters for Members with Disabilities 82 Provider Termination 83 NaviNet 83 Credentialing Practices 84 Confidentiality 85 Fraud and Abuse 87 Environmental Assessment Standards 91 Reporting of Required Reportable Diseases 96 NCQA Compliance Requirements 98 Marketing Policies and Practices P age

82 3.1 GENERAL INFORMATION Introduction West Virginia Family Health (WVFH) has developed policies and procedures to provide guidelines for identifying and resolving issues with practitioners who fail to comply with the terms and conditions of the applicable Practitioner Agreement, WVFH policies and procedures, or accepted Utilization Management Standards and Quality Improvement Guidelines. WV DHHR/BMS policy changes West Virginia Department of Health and Human Resources (DHHR), Bureau of Medical Services (BMS) Policy Changes: In order for WVFH to meet the standards set forth by the Bureau for Medical Services ( BMS ) standard contract, WVFH must promptly implement new policies or changes in policy at the request of BMS. Upon notice from BMS of program or policy changes, WVFH will assess those policies or practices that require practitioner notice. Depending upon the BMS effective date of the change, practitioners cannot always be notified prior to such alterations. WVFH is committed to notifying all appropriate practitioners, via the most appropriate medium, within thirty (30) days of receipt of the notice of a new policy or policy change when sufficient notice is provided by BMS. Additionally, practitioners need to be aware that no regulatory order or requirement of the Departments of Insurance, Health and Human Services or Bureau for Medical Services shall be subject to arbitration with WVFH. Provider manuals This West Virginia Family Health Provider Manual and the Highmark Blue Shield Office Manual are binding upon providers and may be supplemented or superseded, in whole or in part, by other guidance and/or requirements furnished or otherwise made available to providers, provided supplements do not conflict with the applicable federal and state laws and regulations. The Highmark Blue Shield Office Manual for professional providers is available on the Highmark West Virginia Provider Resource Center under Administrative Reference Materials. The Provider Resource Center is accessible from the Highmark West Virginia website at -- select the Provider Resource Center link under HELPFUL LINKS. Continued on next page 81 P age

83 3.1 GENERAL INFORMATION, Continued Practitioner education and sanctioning Network practitioners will be monitored for compliance with administrative procedures, trends of inappropriate resource utilization, potential quality of care concerns and compliance with medical record review standards. Practitioner education is provided through Quality Improvement Nurses and Medical Directors. Network practitioners who do not improve through the provider education process will be referred to the Highmark West Virginia Quality Improvement/Utilization Management Committee for evaluation and recommendations. To request additional information or to obtain a copy of this policy, please contact Provider Services. WVFH encourages its providers to participate in training which promotes sensitivity to the special needs of the West Virginia Medicaid population. Practitioner due process WVFH has established a policy and procedure to define the situations when due process procedures are afforded to practitioners, and to specify the due process procedures available in accordance with federal and state regulations, in particular the Healthcare Quality Improvement Act of The Practitioner Due Process Policy will be updated in accordance with federal and state regulations. To request additional information or to obtain a copy of this policy, please contact Provider Services. Title VI of the Civil Rights Act of 1964 Practitioners are expected to comply with Title VI of the Civil Rights Act of 1964 that prohibits race, color, or national origin discrimination in programs receiving Federal funds. Practitioners are obligated to take reasonable steps to provide meaningful access to services for members with limited English proficiency, including provision of translator services as necessary for these members. Access and interpreters for members with disabilities Practitioner offices are expected to address the need for interpreter services in accordance with the Americans with Disabilities Act (ADA). Each practitioner is expected to arrange and coordinate interpreter services to assist member who are hearing impaired. WVFH will assist practitioners in locating resources upon request. WVFH offers the Member Handbook and other WVFH information in large print, Braille, on cassette tape, or computer diskette at no cost to the member. Please instruct members to call Member Services at to ask for these other formats. Practitioner offices are required to adhere to the ADA guidelines, Section 504, the Rehabilitation Act of 1973 and related federal and state requirements that are enacted from time-to-time. Continued on next page 82 P age

84 3.1 GENERAL INFORMATION, Continued Access and interpreters for members with disabilities (continued) All services are expected to be provided in culturally competent manner to all enrollees, including: those with limited English proficiency or reading skills, those with diverse cultural and ethnic backgrounds, the homeless, and individuals with physical and mental disabilities, regardless of gender, sexual orientation, or gender identity. Provider termination For more information regarding corrective action, termination, and appeal policies and procedures, please see Chapter 2, Unit 2: Network Credentialing Procedures of the Highmark Blue Shield Office Manual. NaviNet Participating providers can access NaviNet 24 hours a day, seven days a week. NaviNet can be used for eligibility and benefits inquiries, claim status inquiries, authorization inquiries, provider/facility directory searches, and provider information updates. Providers can access NaviNet at: 83 P age

85 3.1 CREDENTIALING PRACTICES Credentialing nondiscrimination practices In selecting and credentialing providers for the associated networks, West Virginia Family Health (WVFH) does not discriminate in terms of participation or reimbursement, against any healthcare professional who is acting within the scope of his or her license or certification under state law solely on the basis of the license or certification. In addition, WVFH does not discriminate against professionals who serve high-risk populations or who specialize in the treatment of costly conditions. For additional credentialing information For additional information regarding credentialing and recredentialing for the WVFH networks, please see the Highmark Blue Shield Office Manual s Chapter 2, Unit 2: Network Credentialing Procedures. The Highmark Blue Shield Office Manual is available on the Highmark West Virginia Provider Resource, which is accessible from Highmark Blue Cross Blue Shield West Virginia website at The Provider Resource Center link can be found under HELPFUL LINKS. The manual can be found by selecting Administrative Reference Materials from the Resource Center s main menu. 84 P age

86 3.1 CONFIDENTIALITY Overview All practitioners and providers participating with WVFH have agreed to abide by all WVFH policies and procedures regarding member confidentiality. The performance goal for confidentiality is maintaining patient records secure from public access. Member confidentiality policy Under these policies, the practitioner or provider must meet the following: 1. Provide the highest level of protection and confidentiality of members medical and personal information used for any purposes in accordance with federal and state laws or regulations including the following: a. Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 CFR Parts 160, 162 and 164 b. Patient Protection and Affordable Care Act (PPACA), P.L , enacted on March 23, 2010, and the Health Care and Education Reconciliation Act of 2010 (HCERA), P.L , enacted on March 30, 2010 c. The Health Information Technology for Economic and Clinical Health (HITECH) Act, Title XIII of Division A and Title IV of Division B of the American Recovery and Reinvestment Act of 2009 (ARRA), Pub.L.No (Feb 17, 2009) and related regulations. d. 42 U.S.C. 1396a(a)(7) State plan for medical assistance e. 42 C.F.R et seq. Medical Assistance Safeguarding Information on Applicants and Recipients f. Section 29a of the West Virginia Code 2. Assure that member records, including information obtained for any purpose, are considered privileged information and, therefore, are protected by obligations of confidentiality. 3. Assure that a member s individually identifiable health information as defined by HIPAA, also known as Protected Health Information (PHI), necessary for treatment, payment or healthcare operations (TPO) is released to WVFH without seeking the consent of a member. This information includes PHI used for claims payment, continuity and coordination of care, accreditation surveys, medical record audits, treatment, quality assessment and measurement, quality of care issues, medical management, appeals, case management and disease management. Further, providers will assure that PHI for TPO will be made available to the WV Department of Health & Human Resources, Department of Health, Department of Insurance or Business Associates of WVFH for use without member consent. All other requests for release of or access to PHI will be handled in accordance with federal and state Continued on next page 85 P age

87 3.1 CONFIDENTIALITY, Continued Member confidentiality policy (continued) regulations. WVFH follows the requirements of HIPAA and limits its requests to the amount of PHI that is minimally necessary to meet the treatment, payment, or operational function. 4. The member, or a member s representative including head of household, legal guardian, or durable power of attorney, shall have access to view and/or receive copies of the medical record upon request. There is no charge for the copied medical record if the record is sent to another practitioner or provided directly to the member. The request must allow reasonable notice and follow the specific procedures of the practitioner or provider. 5. All providers are required to conduct environmental security of confidential information and monitor practice and provider sites. Provider and practitioner sites must comply with the Environmental Assessment standards that require that patient records be protected from public access. 6. Medical records must be available for all member visits for established patients. 86 P age

88 3.1 FRAUD AND ABUSE Overview WVFH has a comprehensive policy for handling the prevention, detection, and reporting of fraud and abuse. It is WVFH s policy to investigate any action by members, employees, or practitioners that affects the integrity of WVFH and/or the Medicaid Program. As a Network practitioner, the contract that is signed requires compliance with WVFH s policies and procedures for the detection and prevention of fraud and abuse. Such compliance may include referral of information regarding suspected or confirmed fraud or abuse to WVFH and submission of statistical and narrative reports regarding fraud and abuse detection activities. If fraud or abuse is suspected, whether it is by a member, employee, or practitioner, it is your responsibility to immediately notify WVFH at Recipient Restriction Program WVFH maintains a Recipient Restriction Program, which restricts members who misutilize medical services. WVFH enforces and monitors these restrictions through the following process: Identifying Members who are over utilizing and/or misutilizing medical services. Evaluating the degree of abuse including review of medical claims history, diagnoses and other documentation, as applicable. Proposing whether the Member should be restricted to obtaining services from a single, designated Provider for a period of five years. Sending notification via certified mail to member of proposed restriction, including reason for restriction, effective date and length of restriction, name of designated provider(s) and option to change provider. Sending notification of member s restriction to the designated provider(s). Enforcing the restrictions through appropriate notifications and edits in the claims payment system. Monitoring subsequent utilization to ensure compliance. Changing the selected provider per the member s or provider s request, within thirty (30) days from the date of the request. Reviewing the member s services prior to the end of the five-year period of restriction to determine if the restriction should be removed or maintained, with notification of the results of the review to BMS, member, provider(s) and CAO. Educating members including explanations in handbooks. Continued on next page 87 P age

89 3.1 FRAUD AND ABUSE, Continued Investigating fraud and abuse It is WVFH s policy to discharge any employee, terminate any practitioner, or recommend any member be withdrawn from the Medicaid Program who, upon investigation and referral to the Department of Health and Human Resources, has been identified as being involved in fraudulent or abusive activities. The Department of Health and Human Resources has an established Office of Quality and Program Integrity (OQPI) that is charged with investigating complaints and identifying potential fraud, waste, and abuse occurring within the Medicaid system. Complaints are received from various sources for development, investigation, and appropriate resolution. WVFH works in conjunction with OQPI refer cases and investigate cases to determine if there is a credible allegation of fraud, waste, or abuse. If it is a credible allegation of fraud, waste, or abuse, the complaint is referred to the West Virginia Office of the Inspector General Medicaid Fraud Control Unit (MFCU). MFCU has jurisdiction under federal and state law to investigate West Virginia Medicaid providers for potential fraudulent practices, and the authority to seek criminal and civil remedies when fraudulent practices are discovered. Examples of fraud and abuse Some common examples of fraud and abuse are: Billing or charging Medicaid recipients for covered services Billing for services not rendered Billing for separately for services in lieu of an available combination code Billing more than once for the same service Dispensing generic drugs and billing for brand name drugs Falsifying records Performing inappropriate or unnecessary services Reporting fraud Complaints regarding member fraud should be referred to the West Virginia Office of the Inspector General Investigations and Fraud Management Unit. If Medicaid Fraud is suspected, you must contact the Medicaid Fraud Control Unit at: FRAUDWV ( ); or Complete the online reporting form at: Continued on next page 88 P age

90 3.1 FRAUD AND ABUSE, Continued Reporting fraud (continued) Or submit in writing to: Department of Health and Human Resources Medicaid Fraud Control Unit Office of Inspector General 408 Leon Sullivan Way Charleston, WV False Claims Act West Virginia Family Health maintains a False Claims Act Policy and other policies intended to prevent, detect, investigate and report Medicaid fraud, waste and abuse to West Virginia and federal authorities. Further, pursuant to Section 6032 of the Deficit Reduction Act of 2005, any provider or entity who receives annual Medicaid payments of at least $5 million (cumulative, from all sources) must: 1. Establish written policies for all employees, officers, and contractors of the provider. The policies must provide detailed information about the federal False Claims Act and federal and state whistleblower protections. 2. Providers must include as part of the policies information on how you detect and prevent fraud, waste, and abuse. 3. Your employee handbook must include a description of the federal False Claims Act, including the rights of your employees to be protected as whistleblowers, and how you detect and prevent fraud, waste, and abuse. Obligation to Screen Employees for exclusion from Medicare and Medicaid The Centers for Medicare and Medicaid Services (CMS) requires all providers to screen employees, contractors and subcontractors, individuals and entities, against the exclusion databases as required by 42 CFR to determine if they have been excluded from participation in Medicare or Medicaid. No Medicaid payments can be made for any items or services directed or prescribed by an excluded physician or other authorized person when the individual or entity furnishing the services either knew or should have known of the exclusion. This prohibition applies even when the Medicaid payment itself is made to another provider, practitioner or supplier that is not excluded. 42 CFR (b). Below are links to the exclusion databases: 1. Federal Department of Health & Human Services, Office of Inspector General List of Excluded Individuals and Entities 2. Federal General Services Administration, System for Award Management 89 P age

91 Compliance with the federal Deficit Reduction Act of 2005 and the federal False Claims Act Section 6032 of the Deficit Reduction Act of 2005, requires any network provider receiving annual Medicaid payments of at least $5 million (cumulative, from all sources) to: 1. Establish written policies for all employees, managers, officers, contractors, subcontractors, and agents of the network provider. The policies must provide detailed information about the False Claims Act, administrative remedies for false claims and statements, any state laws about civil or criminal penalties for false claims, and whistleblower protections under such laws, as described in Section 1902(a)(68)(A). 2. Include as part of such written policies detailed provisions regarding the network provider s policies and procedures for detecting and preventing Fraud, Waste, and Abuse. 3. Include in any employee handbook a specific discussion of the laws described in Section 1902(a)(68)(A), the rights of employees to be protected as whistleblowers, and the provider s policies and procedures for detecting and preventing Fraud, Waste, and Abuse 90 P age

92 3.1 ENVIRONMENTAL ASSESSMENT STANDARDS Overview WVFH has established specific guidelines for conducting Environmental Assessment Site Visits, including medical record-keeping standards at PCP, OB/GYN, and other high volume specialty practices. An initial Environmental Assessment will be conducted at all PCP, OB/GYN, and other high volume specialty office sites as part of the credentialing process. The purpose of the site visit is to assure that practitioners are in compliance with WVFH s Environmental Assessment Standards. On-site visits A Provider Relations Representative will schedule an on-site visit at each office site to conduct an Environmental Assessment. The Environmental Assessment must be conducted with the Office Manager or with a practitioner of the practice. The Provider Relations Representative will complete the Initial Environmental Assessment Form and tour the office as well as interview staff and examine the appointment schedule. The Provider Relations Representative will assess the office for evidence of compliance with the Environmental Assessment Standards. The Provider Relations Representative will conduct a follow-up visit within 90 days or until the office site is compliant. The Medical Director will review the Environmental Assessment as part of the initial credentialing process. If any of the standards are not met, the Medical Director will assess the potential impact of the discrepancy to patient care and evaluate the corrective action plan. If the plan is reasonable, the practitioner will continue with the credentialing process. If the plan is not acceptable, the Medical Director may suggest a different corrective action plan or delay the credentialing process until the issue is resolved. If the office is not agreeable to correcting the identified problem, the information will be presented to the Quality Improvement/Utilization Management Committee for review. Special circumstances may be granted based upon size, geographic location of the practice, and potential harm to members. The Provider Relations Representative will communicate the final results to the practitioners. An Environmental Assessment will not be conducted if a new practitioner joins an office site or if the practitioner relocates to an office that has already been reviewed and meets WVFH standards. When credentialing a new practitioner who joins an existing office site, the documentation from that site visit for that office will be included in the new practitioner s initial credentialing file prior to the Quality Improvement/Utilization Management Committee review. Site visits for relocated offices must be conducted prior to the practitioner s recredentialing date. The documentation of that site visit will be included in the recredentialing file. Continued on next page 91 P age

93 3.1 ENVIRONMENTAL ASSESSMENT STANDARDS, Continued On-site Visits (continued) Provider Relations Representatives conduct site visits to assess practice compliance with the Americans with Disabilities Act and Section 504 of the Rehabilitation Act of 1973 for those practices as determined by the Department of Health & Human Resources. PRACTITIONER OFFICE SITE QUALITY EVALUATION MET NOT MET N/A COMMENTS 1. The office is reasonably accessible (noting the ease of entry into and the accessibility of space within the building) for patients with physical and/or sensory disabilities. (ALL) 2. The physical appearance of the office is clean, organized and well maintained for the safely of patients, staff and visitors. (ALL) 3. The waiting area is well lit, has adequate space and seating, and has posted office hours. (ALL) 4. There is adequacy of examining/treatment room space as well as patient interview areas and each are designed to respect patients' dignity and privacy. (ALL) 5. Clinical records are filed in an organized, systematic manner, easily located, and kept in a secure, confidential location and away from patient access. Only authorized persons have access to clinical records. (ALL) 6. The office has a written confidentiality policy to avoid the unauthorized release or disclosure of confidential personal health information including but not limited to computer screens, data disks, e- mails, telephone messages/calls fax machines. (ALL) 7. The medical equipment utilized in the office appears to be adequate, well maintained, up to date, appropriate for the patients' age and appropriate for the specialty of the practice. (ALL) 8. The office has 24-hour medical coverage that is available seven (7) days a week. (ALL) 9. The office has a process to ensure after-hours calls are returned within 30 minutes. (ALL) 10. The office has a process to ensure after-hours calls are communicated to the office by the morning of the following business day. (ALL) Continued on next page 92 P age

94 3.1 ENVIRONMENTAL ASSESSMENT STANDARDS, Continued MET NOT MET N/A COMMENTS 11. The office has mechanisms to assess behavioral health disorders, alcohol and other drug dependence (i.e., screening tool or questionnaire). (PCP, OBGYN) 12. No more than six (6) office visits are scheduled per hour, per practitioner. (ALL) 13. Emergency, life-threatening, medical situations are handled immediately. (ALL EXCEPT BH) 14. Urgent medical care appointments, which require rapid clinical intervention as a result of an unforeseen illness, injury, or condition, are available within 1 day (e.g., high fever, persistent vomiting/diarrhea). (PCP, SPECIALIST) 15. Regular and routine care appointments that are non-urgent but in need of attention are available within 2-7 days (e.g., headache, cold, cough, rash, joint/muscle pain, etc.). (PCP, SPECIALIST) 16. Regular and routine care appointments for routine wellness appointments are available within 30 days (e.g., symptomatic preventive care, well child/patient exams, physical exams, etc.). (PCP, SPECIALIST) 17. Patients with chronic conditions (e.g., diabetes, hypertension, CHF, depression, etc.) are proactively notified by the office and encouraged to schedule an appointment. (PCP) 18. There is a process to assure that patients who either no show or cancel their appointments are contacted & encouraged to reschedule the appointments as evidenced by documentation of such in the medical record (appointment scheduled, reminder card, etc.). (PCP) 19. A reminder call is made by the practice prior to scheduled appointments to encourage attendance with the scheduled visit. (PCP) 20. There is a process confirming that laboratory, diagnostic procedure, and/or consultation appointments were performed and results were received, reviewed, and filed in the patient's medical record. The process: a) Identifies how the laboratory, diagnostic procedures and/or consultation appointments are tracked b) Identifies staff responsible to ensure results are returned to the office Continued on next page 93 P age

95 3.1 ENVIRONMENTAL ASSESSMENT STANDARDS, Continued MET NOT MET N/A COMMENTS c) Identifies when and how staff match test results with patient's chart d) Identifies how the reviewer (practitioner) notifies how the results should be handled. (PCP) 21. There is a process in place to ensure patients are notified of abnormal results. (ALL) 22. Urgent medical care appointments which require rapid clinical intervention as a result of an unforeseen illness, injury, or condition are available within 1 day such as: a) OB: High fever, persistent vomiting / diarrhea, bladder infection, increased swelling. b) GYN: Unusual vaginal discharge or vaginal bleeding post-menopause/hysterectomy, or detection of breast mass/breast lump. (OBGYN) 23. Regular and routine care appointments that are non-urgent but in need of attention are available within 2-7 days: a) OB: Small amount of swelling in ankles or hands, sciatica pain (including hip/leg pain), respiratory infection, UTI symptoms b) GYN: Increased menstrual cramps. (OBGYN) 24. Regular and routine care appointments for routine wellness appointments are available within 30 days (e.g., regular routine obstetrical and gynecological appointments). (OBGYN) 25. Immediate intervention for a life-threatening emergency is required to prevent death or serious harm to patient or others. (BH) 26. Intervention within 6 hours is required for a nonlife-threatening emergency to prevent acute deterioration of the patient's clinical state that compromises patient safety. (BH) 27. Timely evaluation (within 48 hours) is needed for urgent care to prevent deterioration of the patient s condition. (BH) 28. Routine office visits are available (within 10 business days) when the patient's condition is considered to be stable. (BH) Continued on next page 94 P age

96 3.1 ENVIRONMENTAL ASSESSMENT STANDARDS, Continued MET NOT MET N/A COMMENTS 1. An individual clinical record is established, organized, easily located and data is easily retrievable for each patient. (ALL) 2. Each page in the medical record contains the patient's name. Another form of patient identification (e.g., birth date, social security number, identification number, etc.) is documented on the medical record. (ALL) 3. Significant illnesses and medical and behavioral health conditions are indicated on the current problem list and are updated after each office visit and hospitalization. (ALL) 4. Each record indicates which medications have been prescribed, the dosages of each, the date of the initial prescription and/or refill, and the date the medication was discontinued, as applicable. (ALL) 5. Medication & other allergies, adverse reactions, & relevant medical conditions are clearly documented and dated prominently in the record. It is noted if the patient has no known allergies, no history of adverse reactions or relevant medical conditions. (ALL) 6. All entries in the record contain a valid, legible author's signature, which may be a handwritten signature with credentials, printed name & credentials accompanied by handwritten provider initials, or unique electronic identifier with credentials. (ALL) 7. All entries in the record are dated and are legible to someone other than the writer. (ALL) 8. The medical/treatment records have a notation regarding follow-up care, calls or visits, when indicated. The specific time of return is noted in weeks, months, or as needed. (ALL) 95 P age

97 3.1 REPORTING OF REQUIRED REPORTABLE DISEASES Overview Health care providers are required to report certain diseases by state law. This is to allow for both disease surveillance and appropriate case investigation/public follow-up. WVFH may be responsible for: 1) Further screening, diagnosis, and treatment of identified cases enrolled in WVFH as necessary to protect the public s health; or 2) Screening, diagnosis, and treatment of case contacts who are enrolled in WVFH. Detailed infectious disease reporting requirements can be obtained from the Bureau for Public Health within the Department of Health and Human Resources. Primary types of diseases that must be reported The three primary types of diseases that must be reported are: 1. Division of Surveillance and Disease Control, Sexually Transmitted Disease Program. Sexually transmitted diseases (STDs) are required to be reported for disease surveillance purposes and for appropriate case investigation and follow-up. For contact notification, WVFH must refer case information to the Division of Surveillance and Disease Control. The Division has an established program for notifying partners of persons with infectious conditions. This includes follow-up of contacts to individuals with HIV and AIDS. Once notified, contacts who are enrollees of WVFH may be referred back to WVFH for appropriate screening and treatment, if necessary. 2. Division of Surveillance and Disease Control, Tuberculosis Program. Individuals with diseases caused by M. tuberculosis must be reported to the WV Bureau for Public Health, DSDC, TB Program for appropriate identification, screening, treatment and treatment monitoring of their contacts. 3. Division of Surveillance and Disease Control, Communicable Disease Program. Cases of communicable disease noted as reportable in West Virginia must be reported to the local health departments in the appropriate time frame and method outlined in legislative rules. This both provides for disease surveillance and allows appropriate public health action to be undertaken patient education and instruction to prevent further spread, contact identification and treatment, environmental investigation, outbreak identification and investigation, etc. (Note: Per legislative rule, reports of category IV diseases [including HIV and AIDS] are submitted directly to the state health department, not to local jurisdictions.) Continued on next page 96 P age

98 3.1 REPORTING OF REQUIRED REPORTABLE DISEASES, Continued Federal reporting requirements In order to assist WVFH with its obligations to comply with the following Federal reporting and compliance requirements for the services listed below, providers are required to comply with the following federal reporting requirements: Abortions must comply with the requirements of 42 CFR 441. Subpart E Abortions. This includes completion of the information form, Certification Regarding Abortion. For more information, see Chapter 2, Unit 3: OB/GYN Services of this manual (page 9). Hysterectomies and sterilizations must comply with 42 CFR 441. Subpart F Sterilizations. This includes completion of the consent form. For more information, see Chapter 2, Unit 3: OB/GYN Services of this manual (page 8). EPSDT services and reporting must comply with 42 CFR 441 Subpart B Early and Periodic Screening, Diagnosis, and Treatment. For more information, see this manual s Chapter 1, Unit 3: Growing Up Program. Other reporting requirements The data that must be certified include, but are not limited to, enrollment information, encounter data, and other information required by the State of West Virginia and contained in contracts, proposals, and related documents. Additional reporting elements include: provider network, utilization, quality, access, EPSDT, financial data, member satisfaction, HEDIS scores, and number and types of informal and formal grievances and appeals registered by enrollees and providers. 97 P age

99 3.1 NCQA COMPLIANCE REQUIREMENTS Compliance with NCQA accreditation standards Providers acknowledge and agree that certain provisions are required to be in contracts between West Virginia Family Health and providers for compliance with the accreditation standards of the National Committee for Quality Assurance (NCQA). Pursuant to such NCQA compliance requirements, providers agree to acknowledge and cooperate with West Virginia Family Health s quality initiative activities. West Virginia Family Health may utilize provider performance data for activities including, but not limited to, quality improvement activities, public reporting to consumers, transparency activities, and/or any other activity of or relating to West Virginia Family Health compliance with the accreditation standards of the NCQA. 98 P age

100 3.1 MARKETING POLICIES AND PRACTICES Approved marketing practices The list of approved Marketing practices is not intended to be exhaustive. The following list is applicable to WVFH (acting as an Managed Care Organization [MCO] in the State of West Virginia), its agents, subcontractors, and WVFH providers: 1. The MCO is allowed to send outreach materials and non-marketing correspondence to its members. The content of such mailings must be approved by the Bureau of Medical Services (BMS) prior to distribution. 2. Terms such as choose, pick, join, etc. are allowed in marketing materials as long as the Enrollment Broker contractor s telephone number is included. 3. WVFH may send plan specific materials to potential members at the potential member s request. The content of such mailings must be approved by BMS prior to distribution. 4. WVFH may only provide plan specific information during incoming calls from potential members. WVFH may return telephone calls to potential members only when requested to do so by the caller. The content of such call scripts must be approved by BMS prior to distribution. 5. WVFH may respond to direct questions from potential members with accurate information during such telephone calls. 6. WVFH may survey their former and currently enrolled members. 7. WVFH may provide gifts approved by BMS to encourage currently enrolled members to participate in the surveys. 8. WVFH may distribute materials and information that purely educate its members on the importance of completing the State s Medicaid eligibility renewal process in a timely fashion. 9. At BMS s approval, WVFH may provide information about a Qualified Health Plan (QHP) to potential members who could enroll in such a plan as an alternative to the Medicaid managed care plan due to a loss of Medicaid eligibility or to potential members who may consider the benefits of selecting an Medicaid managed care plan that has a related QHP in the event of future eligibility changes. Such information may not be included within marketing materials. Prohibited practices The following policies and practices are prohibited and violate the State BMS contract. This list is not intended to be exhaustive. The following prohibitions are applicable to WVFH, its agents, subcontractors, and WVFH providers: 1. Distributing Marketing materials without prior BMS approval; 2. Using the word, Mountain, or phrase, Mountain Health, Health Bridge, except when referring to Mountain Health Trust, West Virginia Health Bridge, or other State programs; Continued on next page 99 P age

101 3.1 MARKETING POLICIES AND PRACTICES, Continued Prohibited practices (continued) 3. Distributing Marketing materials written above the 6th grade reading level, unless approved by BMS; 4. Offering gifts valued over $15.00 to potential members; 5. Providing gifts to providers for the purpose of distributing them directly to WVFH s potential members or currently enrolled members; 6. Directly or indirectly, engaging in door-to-door, telephone, and other Cold Call Marketing activities; 7. Marketing in or around public assistance offices, including eligibility offices; 8. Using Spam; 9. Making any assertion or statement (orally or in writing) that WVFH is endorsed by CMS, a federal or state government agency, or similar entity; 10. Knowingly marketing to persons currently enrolled in another MCO; 11. Inducing or accepting a member s MCO enrollment or MCO disenrollment; 12. Using terms that would influence, mislead, or cause potential members to contact WVFH, rather than the Enrollment Broker, for enrollment; 13. Portraying competitors in a negative manner; 14. Using absolute superlatives (e.g., the best, highest ranked, rated number 1 ) unless they are substantiated with supporting data provided to BMS; 15. Making any written or oral statements containing material misrepresentations of fact or law relating to WVFH s plan or the Medicaid program, services, or benefits; 16. Making potential member gifts conditional based on enrollment with WVFH; 17. Charging members for goods or services distributed at WVFH or Medicaid events; 18. Charging members a fee for accessing the WVFH s website; 19. Influencing enrollment in conjunction with the sale or offering of any private insurance; 20. Tying enrollment in WVFH with purchasing (or the provision of) other types of private insurance; 21. Using marketing agents who are paid solely by commission; 22. Posting WVFH-specific, non-health related materials or banners in provider offices; 23. Conducting potential member orientation in common areas of providers offices; Continued on next page 100 P a g e

102 3.1 MARKETING POLICIES AND PRACTICES, Continued Prohibited practices (continued) 24. Allowing providers to solicit enrollment or disenrollment in WVFH, or distribute WVFH-specific materials at a Marketing activity (this does not apply to health fairs where providers do immunizations, blood pressure checks, etc. as long as the provider is not soliciting enrollment or distributing plan specific MCO materials); 25. Making charitable contributions or donations from Medicaid funds; 26. Purchasing or otherwise acquiring mailing lists from third party vendors, or for paying BMS s contractors or subcontractors to send plan specific materials to potential members; 27. Referencing the commercial component of WVFH in any Marketing materials; 28. Discriminating against a member or potential member because of race, age, color, religion, natural origin, ancestry, marital status, sexual orientation, physical or mental disability, health status or existing need for medical care, with the following exception: certain gifts and services may be made available to members with certain diagnoses; 29. Assisting with Medicaid MCO enrollment form; 30. Making false, misleading or inaccurate statements relating to services or benefits of WVFH or Medicaid program, or relating to the providers or potential providers contracting with WVFH; and 31. Direct Mail Marketing to potential members. Gifts to potential members WVFH may provide promotional gifts valued at or under $15 to potential WVFH members. WVFH may distribute promotional gifts valued at more than $15 to current members only. A gift worth $15 or less must be based on the retail purchase price of the gift item. WVFH may not provide gifts to providers for the purpose of distributing them potential members, unless such gifts are placed in the providers office common areas and are available to all patients. MCO member gifts WVFH may solicit its currently enrolled members for participation in WVFH activities. WVFH may provide gifts valued at $50.00 or less per member per gift to encourage member attendance or participation in WVFH activities. Member gifts may not be converted to cash. WVFH must not exceed the total annual limit of $ per each member for all gifts. BMS must provide prior approval of all monetary and non-monetary compensation provided to members in exchange for participating in WVFH activities. 101 P age

103 CHAPTER 3: POLICIES AND PROCEDURES UNIT 2: CLAIMS AND BILLING INFORMATION IN THIS UNIT TOPIC SEE PAGE Member Billing Policy 103 Excluded Providers or Credible Allegation of Provider Fraud 104 Claims Submission 105 Timely Filing 107 Prompt Pay 108 Payment Time Frames 108 BMS Reimbursement Hold Harmless 108 Electronic Claims Submission 109 Electronic Remittance Advice (ERA) 111 Claims Review 112 Administrative Claims Review 112 Medical Claims Review 113 Coordination of Benefits 114 Coordination of Benefits Policy 114 Specialty/Fee-For-Service Providers 115 Medicare 116 Nursing Care 117 Subrogation 117 Primary Care Services 119 Claim Coding Software 121 Billing 122 Early and Periodic Screening, Diagnostic, and Treatment 124 (EPSDT) Services EPSDT Claim Submission Time Frame 124 FQHC/RHC Billing Paper Format Requirements EDI Format Requirements 125 Obstetrical Care Services 126 Hospital Services 127 UB-04 Data Elements for Claims Submission 128 Sample UB-04 Claim Form Data Elements for Claims Submission 131 Sample 1500 Claim Form P age

104 3.2 MEMBER BILLING POLICY Policy Payment by West Virginia Family Health (WVFH) is considered payment in full. Under no circumstance, including but not limited to non-payment by WVFH for approved services, may a provider bill, charge, collect a deposit from, seek compensation, remuneration, or reimbursement from or have any recourse against a WVFH member. This provision shall not prohibit collection of copayments on WVFH s behalf made in accordance with the terms of the MCO Provider Agreement between WVFH and the Department of Health and Human Resources, Bureau for Medical Services. Providers may not collect copays from a WVFH member for missed appointments. Practitioners may directly bill Members for non-covered services or services rendered to the member that exceeds coverage or service limitations provided, however, that prior to the provision of such non-covered services, the practitioner must inform the Member in writing and have the member acknowledge receipt in writing: (i) of the service(s) to be provided; (ii) that WVFH will not pay for or be liable for said services; (iii) of the Member s rights to appeal an adverse coverage decision as fully set forth in the Provider Manual; and (iv) absent a successful appeal, that Member will be financially liable for such services. 103 P age

105 3.2 EXCLUDED PROVIDERS OR CREDIBLE ALLEGATION OF PROVIDER FRAUD Excluded providers In accordance with 42 CFR (c)(5), payment under Medicaid is not available for excluded providers except for emergency medical services or items. To be payable, a claim for such emergency items or services must be accompanied by a sworn statement of the person furnishing the items or services specifying the nature of the emergency and why the items or services could not have been furnished by an individual or entity eligible to furnish or order such items or services. No claim for emergency items or services will be payable if such items or services were provided by an excluded provider who, through an employment, contractual, or any other arrangement, routinely provides emergency health care items or services. Credible allegation of fraud 42 CFR requires State Medicaid Agency to suspend all Medicaid payments to a provider after the Agency determines there is a credible allegation of fraud for which an investigation is pending under the Medicaid program against an individual or entity unless the agency has good cause not to suspend payments or suspend payment only in part. The rules governing payment suspensions based upon pending investigations of credible allegations of fraud apply to Medicaid managed care entities. WVFH is required to cooperate with BMS when payment suspensions are imposed for the Medicaid provider by BMS. Upon receipt of the BMS notice for payment suspension, WVFH will be required to suspend payments to the provider within one (1) business day. 104 P age

106 3.2 CLAIMS SUBMISSION Electronic claim submission encouraged WVFH encourages providers to utilize electronic claim billing (see the Electronic Claims Submission section in this unit). When electronic claims submission is not possible, please see the claim filing requirements in the Billing section of this unit. Mail paper copies to the following address: West Virginia Family Health Claims Department P.O. Box Camp Hill, PA Telephone: General information Claim submission procedures for WVFH are as follows: All drug-specific claim information reported to WVFH using the 837P format and the 837 I format MUST be reported with a HCPCS code, such as a J- Code, and an NDC code. Claims submitted without both the appropriate HCPCS Code and NDC will be rejected by Emdeon. Submit claims for all services provided. Payment for CPT and HCPCS codes are covered to the extent that they are recognized by Medicaid or allowed per medical review determination by WVFH. Correct coding (procedure, diagnosis, HCPCS) must be submitted for each service rendered. WVFH utilizes CMS place of service codes to process claims, and they are the only place of service codes that are accepted. WVFH does accept bills through electronic data interchange (EDI) and encourages facilities and providers to submit claims via this format. Paper and EDI claims without the required NPI numbers will be rejected and returned to the provider s EDI clearinghouse or returned via US Postal Service to the billing address on the claim form. Paper claims will be handled just like rejected EDI claims and will not be in WVFH s claim system. Providers will be held to WVFH s timely filing policies in regards to submission of the initial and corrected claims. Correct/current member information, including WVFH Member ID Number, must be entered on all claims. The format is 8 digits. Please allow four to six weeks for an Explanation of Payment (EOP) or remittance advice. It is the practitioner s responsibility to research the status of a claim. Timely filing criteria for initial bills are 12 months from the date of service or payment by the primary carrier. Corrected claims or requests for review are considered if information is received within the 180 day follow-up period from the date on the EOP. Continued on next page 105 P age

107 3.2 CLAIMS SUBMISSION, Continued General information (continued) WVFH is the payer of last resort when any commercial or Medicare plan covers the member. WVFH is obligated to process claims involving auto insurance or casualty services as the primary payer if bills do not include a notation or payment by any insurance that is not a commercial or Medicare plan and WVFH will pursue recovery from the other carrier. Claims must be submitted within WVFH s timely filing guidelines. Any reimbursement or coding changes made by BMS to its current inpatient and outpatient fee schedules shall be implemented by WVFH the month BMS notifies WVFH of such change. There will be no adjustments made to previously processed claims due to any retroactive change implemented by BMS. 106 P age

108 3.2 TIMELY FILING Policy Practitioners must submit a complete original industry standard claim form within 365 calendar days after the date of service or the date a primary payer paid or denied the claim. Paper claims If you bill on paper, WVFH will only accept paper claims on a 1500 Form or a UB-04 Form (or their replacements). No other billing forms will be accepted. Paper claims that are not received on original forms with red ink may delay final processing as original forms are required for every claim submission. EPSDT and primary care services All EPSDT claims and primary care services should be submitted within 60 calendar days from the date of service to permit accurate member outreach. Claim inquiries Any claim that has been submitted to WVFH but does not appear on an EOP within sixty (60) days following submission should be researched by the practitioner. Call the WVFH Provider Services Department at to inquire whether the claim was received and/or processed. Exceptions to timely filing Exceptions to timely filing criteria are evaluated upon receipt of documentation supporting the request for the exception. Upon approval, exceptions are granted on a one-time basis, and the claim system is noted accordingly. WVFH secondary Practitioners must bill within 12 months from the date of an EOB from the primary carrier when WVFH is secondary. An original bill along with a copy of the EOB is required to process the claim. Requests for reviews/corrections of processed claims must be submitted within 180 days from the date of the corresponding remittance advice. All claims submitted after the 12-month period for initial claims or after the 180 day follow-up period from the date on the remittance will be denied. 107 P age

109 3.2 PROMPT PAY Definitions A claim is defined as a bill for services, a line item of service, or all services for one recipient within a bill. A clean claim is defined as one that can be processed without obtaining additional information from the provider of the service or from a third party. It does not include a claim from a provider who is under investigation for fraud or abuse, or a claim under review for medical necessity. Payment time frames WVFH agrees to make timely claims payments to both its contracted and non-contracted providers. WVFH shall pay all in-network provider Clean Claims from subcontractors, which shall include Provider, for Covered Services within thirty (30) calendar days of receipt, except to the extent subcontractors or Provider have agreed to later payment in writing. WVFH shall pay all electronic out-of-network clean claims within 30 days and all paper out-of-network clean claims within 40 days from the date of receipt, except to the extent the provider has agreed to later payment in writing. WVFH agrees to specify the date of receipt as the date WVFH receives the claim, as indicated by its date stamp on the claim, and date of payment as the date of the check release or other form of payment release to the provider. WVFH pays in-network providers interest at 7% per annum, calculated daily for the full period in which the clean claim remains unpaid beyond the 30-day clean claims payment deadline. Interest owed to the provider must be paid on the same date as the claim. MCO shall process all other claims, except those from providers under investigation for fraud and abuse, within twelve (12) months of the date of receipt. BMS Reimbursement Hold Harmless The Bureau of Medical Services (BMS) is not liable or responsible for payment of covered services rendered to Members pursuant to provider agreement. 108 P age

110 3.2 ELECTRONIC CLAIMS SUBMISSION Overview WVFH can accept claims electronically through Emdeon or RelayHealth. WVFH encourages practitioners to take advantage of our electronic claims processing capabilities. Submitting claims electronically offers the following benefits: Faster Claims Submission and Processing Reduced Paperwork Increased Claims Accuracy Time and Cost Savings Payer IDs For submission of professional or institutional electronic claims for WVFH, please refer to the following grid for Emdeon Payer IDs and RelayHealth CPIDs (Clearinghouse Process ID): CPID PAYER NAME PAYER ID CLAIM TYPE West Virginia Family Health (WVFH) Professional West Virginia Family Health (WVFH) Institutional Requirements for submitting claims through Emdeon and RelayHealth To submit claims to WVFH please note the Payer ID Number is WVFH has a health plan specific edit through Emdeon and RelayHealth for electronic claims that differ from the standard electronic submission format criteria. The edit requires a WVFH assigned 8-digit member identification number, the member number field allows 8 or 11 digits to be entered. For practitioners who do not know the member s WVFH identification number, it is acceptable to submit the member s Medicaid Recipient Number on electronic claims. In addition to edits that may be received from Emdeon and RelayHealth, WVFH has a second level of edits that apply to procedure codes and diagnosis codes. Claims can be successfully transmitted to Emdeon and RelayHealth, but if the codes are not currently valid they will be rejected by WVFH. Practitioners must be diligent in reviewing all acceptance/rejection reports to identify claims that may not have successfully been accepted by Emdeon, RelayHealth, and WVFH. Edits applied when claims are received by WVFH will appear on an EDI Report within the initial acceptance report or Claims Acknowledgment Report. A claim can be rejected if it does not include an NPI and current procedure and diagnosis codes. Continued on next page 109 P age

111 3.2 ELECTRONIC CLAIMS SUBMISSION, Continued Requirements for submitting claims through Emdeon and RelayHealth (continued) To assure that claims have been accepted via EDI, practitioners should receive and review the following reports on a daily basis: Emdeon -- Provider Daily Statistics (RO22) Emdeon -- Daily Acceptance Report by Provider (RO26) Emdeon -- Unprocessed Claim Report (RO59) RelayHealth Claims Acknowledgment Report (CPI ) RelayHealth Exclusion Report (CPI ) RelayHealth Claims Status Report (CPA ) If you are not submitting claims electronically, please contact your EDI vendor for information on how you can submit claims electronically. You may also call Emdeon directly at or RelayHealth at WVFH will accept electronic claims for services that would be submitted on a standard 1500 Form (02/12) or a UB-04 Form, or other successor form. However, the following cannot be submitted as attachments along with electronic claims at this time: Claims with EOBs Services billed by report The PCP Referral Form (paper version) HIPAA 5010 The 5010 version of the HIPAA electronic transactions is required in order to support the transfer of ICD-10 diagnosis code and ICD-10 procedure code data on claims and remittances. Effective January 1, 2012, only version 5010 transactions will be accepted. The billing provider address submitted on claims must be a physical address. Claims submitted via Emdeon or RelayHealth will be rejected if a P.O. Box number is submitted as the billing address. In order to prevent claims from being rejected, please be sure to submit a physical address as the billing address. 110 P age

112 3.2 ELECTRONIC REMITTANCE ADVICE (ERA) ERA overview Providers may receive electronic claims remittance advice (ERA). WVFH uses Emdeon to transfer the 835 Version 5010A Healthcare Claim Remittance Advice to claim submitters. Rules for format, content, and field values can be found in the Implementation Guides available on the Washington Publishing Company s website at Due to the evolving nature of HIPAA regulations, these documents are subject to change. Substantial effort has been taken to minimize conflicts or errors. There is a distinct data variation between the paper WVFH Claims Remittance Advice and the 835 Transaction. The difference occurs in the code sets that tell claim submitters the results of each claim s adjudication. Few WVFH and HIPAA Adjustment Reason Codes have solid, unambiguous matches at the same level of detail. A crosswalk has been created in attempt to ease the code set transition and can be located on WVFH s website at P age

113 3.2 CLAIMS REVIEW Claims review process WVFH will review any claim that a practitioner feels was denied or paid incorrectly. The request may be conveyed in writing or verbally through WVFH s Provider Services Department if the inquiry relates to an administrative issue. Please forward all the appropriate documentation, i.e. the actual claim, medical records, and notations regarding telephone conversations, in order to expedite the review process. Initial claims that are not received within the 12 month timely filing limit will not qualify for review. All follow-up review requests must be received within 180 calendar days of the initial Explanation of Payment (EOP) or remittance advice. WVFH cannot accept verbal requests to retract claim(s) overpayments. Providers may complete and submit a Refund Form, found under Provider Forms and Reference Materials at and also located in this manual s Appendix, or write a letter that contains all of the information requested on the Refund Form along with your check to: West Virginia Family Health Attention: Provider Correspondence P.O. Box Pittsburgh, PA Administrative claims disputes Claims that need to be reviewed based upon administrative, policy, or processing issues can be faxed to or discussed with a Provider Services Representative via a phone call to WVFH at Appropriate documentation may be sent via mail, i.e. the claim, medical record, referral form, and notations regarding telephone conversations to: West Virginia Family Health Attention: Claims Review Department P.O. Box Camp Hill, PA For inquiries received in the mail, Claims Review Representatives evaluate whether the documentation attached to the claim is sufficient to allow it to be reconsidered. Inquiries received in the mail that qualify for adjustments will be reprocessed, and claim information will appear on subsequent EOPs. Claims that do not qualify for reconsideration will be responded to via a letter. All review requests must be received within 180 days of the initial EOP. Continued on next page 112 P age

114 3.2 CLAIMS REVIEW, Continued Medical claims review Claims rejected for services that did not have medical records attached or the appropriate referrals or authorizations are subject to a Medical Management Review. All claim records should be sent to WVFH. When submitting a written request for a claim review, please provide: A copy of the WVFH Explanation of Payment (EOP) The member s name and WVFH Identification Number The reason the review is requested and include as much supporting documentation as possible to allow for a complete and comprehensive review Date(s) of service in question A copy of the medical record for the service(s) in question (if applicable) In the event that the claim cannot be reprocessed administratively, a medical necessity review is undertaken. The records will be reviewed by a medical review nurse. If the medical review nurse cannot approve the services, a WVFH Medical Director makes the final decision to approve or deny the claim. A final decision is made within 30 days from receipt of the inquiry. If the Medical Director does not approve the services, a denial letter is sent to the practitioner. If the practitioner is not satisfied with the results of the medical necessity review, a First Level Appeal can be requested. Claims inquiries for administrative/medical review should be mailed to: West Virginia Family Health Attention: Clinical Provider Appeals P.O. Box Pittsburgh, PA P age

115 3.2 COORDINATION OF BENEFITS Coordination of benefits policy Some WVFH recipients have other insurance coverage. WVFH, like the Medicaid Program, is the payer of last resort on claims for services provided to members with other insurance coverage. WVFH may not delay or deny payment of claims unless the probable existence of third party liability is established at the time the claim is submitted. WVFH will process and pay EPSDT visits as primary even when our records indicate WVFH is secondary and a primary plan exists if an explanation of benefits (EOB) is not attached. If an EOB is attached to the EPSDT or prenatal claim, coordination of benefits will be applied. We will continue to coordinate benefits and require the primary EOB when submitting the delivery claim. Billing process when WVFH is the secondary payer In order to receive payment for services provided to members with other insurance coverage, the practitioner must first bill the member s primary insurance carrier using the standard procedures required by the carrier. Upon receipt of the primary insurance carrier s EOB, the practitioner should submit a claim to WVFH. The practitioner must: 1. Follow all WVFH referral and authorization procedures. 2. File all claims within timely filing limits as required by the primary insurance carrier. 3. Submit a copy of the primary carrier s EOB with the claim to WVFH within 365 days of the date of the primary carrier s EOB. 4. Be aware that secondary coverage for covered fee-for-service items is provided according to a lesser-of benefits calculation. 5. The amount billed to WVFH must match the amount billed to the primary carrier. WVFH will coordinate benefits; the provider should not attempt to do this prior to submitting claims. When a claim is submitted by a practitioner without an EOB from the auto insurance or a casualty plan, and the original bill does not include any notation of a primary payer payment, WVFH must take a primary position on the claim and not deny to the extent that plan criteria was followed. The practitioner has the option of submitting an original claim; however, it must be submitted within 12 months. These claims will be denied for timely filing if they are not received within 12 months of service. The 12-month rule for Third Party Liability DOES apply to auto and casualty when the practitioner attaches either an EOB or auto casualty exhaustion letter. If the practitioner submits the claim with the EOB, WVFH will coordinate benefits. Continued on next page 114 P age

116 3.2 COORDINATION OF BENEFITS, Continued Conflict in primary coverage status If a member indicates they no longer have primary coverage, but the State System contains information indicating other medical coverage is still active, the member should contact his or her caseworker to have the State System updated. If this is not possible, the practitioner may contact the primary carrier and request written verification of the coverage. When WVFH receives a letter from the primary carrier indicating that the member no longer has coverage, WVFH will use the letter to investigate the situation and verify if the coverage is cancelled and if there is a new plan covering the member. If WVFH s investigation confirms that the member no longer has primary coverage, WVFH will submit an electronic request to the State to update the system. WVFH will update our system immediately and reprocess claims finalized within the 180 day period prior to the date of the onset of the investigation. Specialty/ fee-for-service providers If a member has other coverage, the other carrier is always the primary insurer. The specialist will bill the other insurer and the other insurer will issue payment with an EOB, which outlines the payment made for each procedure. The specialist will then submit a copy of the EOB with a copy of the claim to WVFH for secondary coverage. The claim must be received by WVFH within 12 months of the date of the EOB. If required, all WVFH authorization and referral requirements must be met in order for payment to be issued. If the member has commercial insurance, and the commercial carrier s payment is greater than WVFH s payment if WVFH were primary, then the following reimbursement example would apply. The primary carrier amount is the basis for the benefit determination of WVFH s liability when the practitioner is a Network practitioner with the primary plan. The primary carrier allowable paid amount is used as the basis for the benefit determination of WVFH s liability when there is a patient responsibility remaining after the primary carrier has processed the claim. Example of practitioner participating with Primary Plan: Practitioner Charges $1,500 Primary Carrier Allowable $1,000 Primary Payment (80% of Allowable) $800 WVFH Allowable if Primary $600 WVFH compares the Primary Carrier Payment to the WVFH Allowable $800 vs. $600 WVFH does not issue payment $0 Example of patient responsibility remaining after Primary plan payment: Practitioner Charges $1,500 Primary Care Allowable $1,000 Primary Payment (80% of Allowable) $800 Patient Responsibility Under Primary Plan $200 WVFH Allowable if Primary $850 WVFH compares the Primary Carrier Payment to the WVFH Allowable $800vs. $850 WVFH Issues Payment $50 Continued on next page 115 P age

117 3.2 COORDINATION OF BENEFITS, Continued Medicare Often, a WVFH member s other insurance carrier is Medicare Fee-for-Service. When Medicare is the other insurance, the following processing criteria applies: Referrals and authorizations are not required for services covered by Medicare. Once Medicare benefits have been exhausted, or if a service is not covered by Medicare WVFH referral and authorization criteria will apply. For Medicare Part A and Medicare Part B services, coverage is provided according to a benefits-less-benefits calculation. Example A WVFH determines the amount that would normally be paid under the plan using the allowable amount from the Medicare Plan as the billed amount. If the amount WVFH would pay is more than the amount Medicare pays, then WVFH may pay the difference up to the maximum allowable, contingent on the benefit less benefit calculation. If the amount WVFH would pay is equal to or less than the amount Medicare pays, WVFH does not issue any additional payment. For Medicare services that are not covered by Medicaid or WVFH, WVFH must pay cost sharing to the extent that the payment made under Medicare for the service and the payment made by WVFH does not exceed eighty percent (80%) of the Medicare approved amount. Example B Practitioner s Charges $1,500 Practitioner s Charges $1,500 Deductible is satisfied -0- Deductible is satisfied -0- Medicare Allowable $1,000 Medicare Allowable $1,000 Medicare Payment (80% of Allowable) $800 Medicare Payment (80% of Allowable) $800 WVFH Allowable if Primary $600 WVFH Allowable if Primary $850 WVFH compares the Medicare Payment to the WVFH Allowable $800 vs. $600 WVFH compares the Medicare Payment to the WVFH Allowable $800 vs. $850 WVFH does not issue payment -0- WVFH Issues Payment for the Difference $50 Example C Practitioner s Charges $1,500 Medicare Allowable $1,000 Medicare applies $50 to Satisfy the $50 Deductible Medicare Payment (80% of Allowable) $760 Remaining after Deductible is Met WVFH Allowable if Primary $850 WVFH compares the Medicare Payment to the WVFH Allowable $760 vs. $850 WVFH Issues Payment for the Difference $90 Continued on next page 116 P age

118 3.2 COORDINATION OF BENEFITS, Continued Nursing care WVFH coordinates benefits with a commercial plan using a benefits-less-benefits approach for limited nursing care services and for expanded services. However, for these specific services only, the total amount billed to the primary plan will be the basis for the benefit determination of WVFH s liability. Example A Nursing Charges $1,000 Primary Carrier Allowance $600 Primary Carrier Payment $500 WVFH Allowable If Primary $800 WVFH compares the Primary Carrier Payment to the WVFH Allowable $500 vs. $800 WVFH Issues Payment $300 WVFH s normal claims processing procedures for Enrollees with other primary insurance require that a primary carrier Explanation of Benefits (EOB) be submitted for each date of service. Subrogation According to WVFH s agreement with BMS, if a member is injured or becomes ill through the act of a third party, medical expenses may be covered by casualty insurance liability insurance or litigation. Any correspondence or inquiry forwarded to WVFH by an attorney, practitioner of service, insurance carrier, etc. relating to a personal injury accident or trauma-related medical service, or which in any way indicates that there is, or may be, legal involvement, will be handled by WVFH s Legal Department. Claims submitted by a provider and without an EOB statement from auto insurance or casualty plans without any notation on the original bill of the primary payer, will be processed by WVFH similar to any other claims. WVFH may neither unreasonably delay payment nor deny payment of claims because they are involved in injury stemming from an accident, such as a motor vehicle accident, where the services are otherwise covered. Timely filing criteria of twelve (12) months applies, and original claims must be received timely to be eligible for payment. EOBs or auto/workers compensation/casualty exhaustion letters qualify for consideration if they are received within twelve (12) months of the date of the EOB/letter along with submission of the initial bill in order for WVFH to coordinate benefits. All requests from legal representatives, and/or insurers for information concerning copies of patient bills or medical records must be submitted to WVFH s Legal Department. A cover letter identifying the date and description of the injury, Continued on next page 117 P age

119 3.2 COORDINATION OF BENEFITS, Continued Subrogation (continued) requested dates of services for billing statements, and release of information signed by the member should be forwarded to the following address: West Virginia Family Health Attention: Legal/Regulatory Affairs P.O. Box 1948 Parkersburg, WV P age

120 3.2 PRIMARY CARE SERVICES PCP reporting PCPs are required to report all the services they provide for WVFH members to WVFH. To facilitate reporting, WVFH will accept encounter information on the industry standard claim forms or the claim can be submitted via EDI. Charges for encounters/visits should be submitted within sixty (60) days from the date of service but will be accepted up to 12 months from the date of service. The encounter information will be reported back to the PCP on an EOP. Practitioners are required to report all services provided to WVFH members with primary insurance coverage by submitting a claim with a copy of the explanation of benefits regardless of whether or not additional payment is expected. Members seeking care, regardless of primary insurer, are required to contact their PCP and use Network practitioners or obtain appropriate authorization for practitioners outside of the network. Vaccines for Children (VFC) All Medicaid eligible recipients under 19 years of age are eligible for Vaccines For Children (VFC) vaccines. Providers should follow the CDC s recommendations about implementing a two-directional borrowing policy when vaccine supplies are depleted. For this policy, providers purchase an initial inventory of appropriate private stock vaccines, and if the private stock vaccine is not used and is nearing the expiration date, the clinic can use the private stock on VFC-eligible children and document on the borrowing form that private stock vaccine was administered to a VFC-eligible child because the private stock was short-dated. The clinic can then replace the used private stock with VFC vaccine and document when that private stock was replaced. Billing for fluoride varnish applications WVFH will reimburse those PCPs properly certified for the application of topical fluoride varnish on a fee-for-service basis. To receive payment for this service, the provider must complete training through West Virginia University School of Dentistry. The Bureau of Medical Services (BMS) allows coverage of two fluoride varnish applications per year (one every six months). The first application must be provided and billed in conjunction with a comprehensive well-child exam as reported under the CPT codes listed in the table below. The second fluoride varnish application can be reimbursed during the 12-month subsequent period, Continued on next page 119 P age

121 3.2 PRIMARY CARE SERVICES, Continued Billing for fluoride varnish applications and may be billed in conjunction with the HCPCS code outlined in the table below. CODE DESCRIPTION COMMENTS D1206 D0145 Comprehensive well-child exam codes for children less than 1 year and up to age 4 (note FV coverage under this program is only through age 3) Topical fluoride varnish; therapeutic application for moderate to high caries risk patients. Oral Evaluation for patient under three years of age and counseling with primary caregiver. Oral evaluation and counseling are components of comprehensive well child exams Covered 2 times per year for children up to age 3; 1st application must be billed in conjunction with one of the comprehensive well child exam codes listed above Covered once per year in conjunction with 2nd fluoride varnish application; cannot be covered when comprehensive wellchild exam is billed on the same day and at least 180 days after billing for the comprehensive well child-exam In order to bill (D1206) and receive reimbursement PCPs must submit a copy of the training certificate to: West Virginia Family Health Provider Correspondence Attention: Training Certification P.O. Box Pittsburgh, PA At the top of the certificate, please include your Medicaid provider identification number and/or WVFH Provider Number. PCPs will not be reimbursed for providing the topical fluoride varnish before we have a copy of the training certificate on file. Your practice will receive written notification confirming receipt of your certificate and provide a date when you may begin billing. 120 P age

122 3.2 CLAIM CODING SOFTWARE Verifying clinical accuracy WVFH uses a fully automated coding review product that programmatically evaluates claim payments to verify the clinical accuracy of professional claims in accordance with clinical editing criteria. This coding program contains complete sets of rules that correspond to CPT-4, HCPCS, ICD-10, AMA, and CMS guidelines (or successor forms and guidelines) as well as industry standards, medical policy, and literature and academic affiliations. The program used at WVFH is designed to assure data integrity for ongoing data analysis and reviews procedures across dates of service and across providers at the claim, practitioner, and practitioner-specialty level. 121 P age

123 3.2 BILLING Clean claim requirements A clean claim as used in this section means a claim for payment for a health care service that has no defect or impropriety. A defect or impropriety shall include lack of required substantiating documentation or a particular circumstance requiring special treatment that prevents timely payment from being made on the claim. A claim from a health care provider who is under investigation for fraud or abuse regarding that claim will not be considered a clean claim. In addition, a claim shall be considered clean if the appropriate corresponding referral has been submitted or the appropriate authorization has been obtained in compliance with WVFH s Provider Manual and the following elements of information are furnished on a standard UB-04 or 1500 form (or their replacements with CMS designations, as applicable) or an acceptable electronic format through a WVFH-contracted clearinghouse: 1. Patient name; 2. Patient medical plan identifier; 3. Date of service for each covered service; 4. Description of covered services rendered using valid coding and abbreviated description; 5. ICD-10 surgical diagnosis code (as applicable) (or its replacement); 6. Name of practitioner/provider and plan identifier; 7. Provider tax identification number; 8. Valid CMS place of service code; 9. Billed charge amount for each covered service; 10. Primary carrier EOB when patient has other insurance; 11. All applicable ICD-10-CM diagnosis codes inpatient claims include diagnoses at the time of discharge or in the case of emergency room claims, the presenting ICD-10-CM diagnosis code (or any replacements); 12. DRG code for inpatient hospital claims. Completion of claim forms WVFH processes medical expenses upon receipt of a correctly completed CMS form or correctly completed UB-04. Sample copies of a UB-04 and a 1500 form can be found at the end of this unit. A description of each of the required fields for each form is identified later in this unit. Paper claim forms must be submitted on original forms printed with red ink. A claim without valid, legible information in all mandatory categories is subject to rejection/denial. To assure reimbursement to the correct payee, the WVFH practitioner number must be included on every claim. Continued on next page 122 P age

124 3.2 BILLING, Continued Completion of claim forms (continued) To comply with encounter data reporting, PCPs and specialty care practitioners must submit claims under the individual practitioner NPI number rather than the practice or group number. Any claim billed on a CMS form must include the individual practitioner identification number (box 31 on the 1500 Form). Exception: All Hospital Based providers are required to bill with their Group NPI in the equivalent of box 33 on the HCFA form. Please note that it is extremely important to promptly notify WVFH of any change that involves adding practitioners to any group practice, as failure to do so may result in a denial of service. WVFH will process claims utilizing individual practitioner numbers even if the individual practitioner number is not included on the claim. The only exception to the individual practitioner number requirement applies to UB charges for practitioner services when an EOP is issued to a hospital facility. WVFH recommends that practitioners submit the appropriate copy of the Referral Form (if the telephonic DIVA paperless system is not used) with their claim in order to facilitate proper reimbursement. All claims must have complete and accurate ICD-10-CM (or its replacement) diagnosis codes for claims consideration. If the diagnosis code requires, but does not include the fourth or fifth digit classification, the claim will be denied. Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading information may be guilty of a criminal act punishable under law and may be subject to civil penalties. By signing a claim for services, the practitioner certifies that the services shown on the claim were medically indicated and necessary for the health of the patient and were personally furnished by the practitioner or an employee under the practitioner s direction. The practitioner certifies that the information contained in the claim is true, accurate, and complete. Claims filing address WVFH s claim office address is: West Virginia Family Health Claims Processing Department P.O. Box Camp Hill, PA Questions? Any questions concerning billing procedures or claim payments can be directed to WVFH s Provider Services Department at P age

125 3.2 EARLY AND PERIODIC SCREENING, DIAGNOSTIC, AND TREATMENT (EPSDT) SERVICES EPSDT claim submission time frame All Early and Periodic Screening, Diagnostic and Treatment (EPSDT) screening services, including vaccine administration fees, should be submitted to WVFH on an industry standard claim form or via EDI within sixty (60) days from the date of service to permit timely member outreach. Claims will be accepted up to 365 days following the date of service, but will result in member and provider outreach for missing EPSDT screens until the claim is submitted. FQHC/RHC billing Federally Qualified Health Centers (FQHCs)/Rural Health Centers (RHCs) Claims for services rendered to Medicaid members must be filed by the RHC/FQHC on the UB04 claim form or the ASC X12N 837 (005010X096A1) electronic claim format (or successor forms and formats). The encounter code is T1015, billed with Revenue Code 52X for a medical visit. The RHC/FQHC claim must list actual CPT/HCPCS procedure codes and appropriate revenue codes to identify the services included in the encounter. Each procedure code must have the EP modifier. The facility may bill the actual charge or indicate a charge of zero for those individual services, but must bill the total charge for the encounter paper format requirements All EPSDT screening services must be reported with the age-appropriate evaluation and management code ( , , and 99435) along with the EP modifier and ICD10 (or its replacement) codes V20 V202, V70, or V703 to V709. The EP modifier must follow the evaluation and management code in the first line of Block 24D on the claim form. Use CPT Modifier (52 or 90) plus CPT code when applicable. Diagnosis codes V20.0, V20.1 or V20.2 must be noted in Box 21 and should be used except when billing for newborns in an inpatient setting (POS 21). V30.00 is primary with V20.0, V20.1 or V20.2 as secondary. Report visit code 03 in box 24(h) of the1500 form (or its replacement) when providing EPSDT screening service. When a referral is made for follow up on a defect, physical or mental illness or a condition identified through an EPSDT screening, referral code indicator Y must be listed in box 24H of the 1500 form (or its replacement). Continued on next page 124 P age

126 3.2 EARLY AND PERIODIC SCREENING, DIAGNOSTIC, AND TREATMENT (EPSDT) SERVICES, Continued 1500 EDI format requirements All EPSDT screening services must be reported with the age-appropriate evaluation and management code ( , , and 99435) along with the EP modifier. The EP modifier must follow the evaluation and management code in the first position on the claim form. Use CPT Modifier (52 or 90) plus CPT code when applicable. Populate the SV111 of the 2400 loop with a yes for an EPSDT claim (this is a mandatory federal requirement). Populate the Data Element CLM12 in the 2300 Claim Information Loop with 01 (meaning EPSDT). 125 P age

127 3.2 OBSTETRICAL CARE SERVICES Intake visit and PRSI The first visit with an obstetrical patient is considered the intake visit, or if a patient becomes a WVFH member during the course of her pregnancy, her first visit as a WVFH member is considered to be her intake visit. At the intake visit, a West Virginia Prenatal Risk Screening Instrument (PRSI) form must be completed. A copy of the PRSI must be faxed to WVFH s Maternity Case Management Department within 2-5 business days of the intake visit and at least 30 days prior to delivery. The PRSI Form is not a claim; however, the PRSI Form must be received by WVFH in order to process the claim for the intake visit. The initial prenatal visit MUST be rendered within the first trimester and the WV PRSI Form must be completed during the visit and faxed to WVFH s Maternity Case Management department at within 2-5 business days of the visit. Billing visits and delivery Obstetric practitioners are reimbursed on a per visit basis. All visits and dates of service must be included on the claim form and identified with appropriate maternity codes for appropriate reimbursement. Delivery charges are to be coded with CPT Codes. The date billed for a Delivery Code, in CPT code format, must be the actual date of service. Submit claims on an industry standard form within twelve (12) months to receive payment for the visit. Newborn charges All charges for newborns that become enrolled in the plan are processed under the newborn name and newborn s WVFH identification number. For prompt payment, please submit claims with the newborn patient information or the claim will be pended for manual research. Inpatient hospital bills for newborns should be submitted separately from the mom s confinement. 126 P age

128 3.2 HOSPITAL SERVICES Overview Hospital claims are submitted to WVFH on a UB-04 Form. To assure that claims are processed for the correct member, the member s eight-digit WVFH identification number must be used on all claims. Practitioners rendering services in an outpatient hospital clinic should include their individual provider number on the claim when submitting their claim. To aid in the recording of payment, patient account numbers recorded on the claim form by the practitioner are indicated in the Patient ID field on the WVFH EOP. 127 P age

129 3.2 UB-04 DATA ELEMENTS FOR CLAIMS SUBMISSION UB-04 DATA ELEMENTS FOR SUBMISSION OF CLAIMS FOR PAPER CLAIMS Note: EDI Requirements Must be Followed for Electronic Claims Submission `` Field Description Requirements 1 Practitioner Name, Address, Phone Number Required 2 Unlabeled Field Not Required 3 Patient Control Number Required 4 Type of Bill Required 5 Federal Tax Number Required 6 Statement Covers Period Required 7 Covered Days Required, If Inpatient 8 Non-covered Days Required, If Inpatient 9 Coinsurance Days Required, if inpatient 10 Lifetime Reserve Days Not Required 11 Unlabeled Field Not Required 12 Patient Name Required 13 Patient Address Required 14 Patient Birth Date Required 15 Patient Sex Required 16 Patient Marital Status Not Required 17 Admission/Start of Care Date Required, If Inpatient 18 Admission Hour Required, If Inpatient 19 Admission Type Required, If Inpatient 20 Source or Admission Required, if inpatient 21 Discharge Hour Required 22 Patient Status Required 23 Medical Record Number Not Required Condition Codes Minimum of One Required, If Applicable 31 Unlabeled Field Not Required Occurrence Codes and Dates Minimum of One Required, If Applicable 36 Occurrence Span Codes and Dates Minimum of One Required, If Applicable 37 Internal Control Number Not Required 38 Responsible Party Name and Address Not Required Value Codes and Amounts Required for DRG Reimbursement, Value Code Record Type 41 must be entered as ZZ and DRG Code must be entered in Value Amount Field 42 Revenue Codes Required 43 Descriptions Required 44 HCPCS/Rates Required, If Outpatient 45 Service Dates Required, If Outpatient 46 Service Units Required 47 Total Charges Required 48 Non-covered Charges Required, If Applicable Continued on next page 128 P age

130 3.2 UB-04 DATA ELEMENTS FOR CLAIMS SUBMISSION, Continued Field Description Requirements 49 Unlabeled Field Not Required 50 Payer Identification Required 51 Practitioner Number WVFH Practitioner Identification Number Required 52 Release of Information Certification Indicator Not Required 53 Assignment of Benefits Not Required 54 Prior Payments Required, If Applicable 55 Estimated Amount Due Not Required 56 Unlabeled Field Not Required 57 Unlabeled Field Not Required 58 Insured s Name Required 59 Patient Relationship to Insured Not Required 60 Certificate-Social Security Number-Health Insurance Claim-Identification Number WVFH Enrollee Identification Number Required (11-digit MA Recipient Number acceptable for electronic claims) 61 Group Name Required 62 Insurance Group Number Not Required 63 Treatment Authorization Code Required, If Applicable 64 Employment Status Codes Not Required 65 Employer Name Not Required 66 Employer Location Not Required 67 Principal Diagnosis Code Required Other Diagnosis Codes Required, If Applicable 76 Admitting Diagnosis Code Required, If Applicable 77 E Code Not Required 78 Unlabeled Field Not Required 79 Procedure Code Method Used Not Required 80 Principal Procedure Code and Date Required, if inpatient only 81 Other Procedure Codes and Date Required, if inpatient only 82 WVFH Individual Provider ID Number Required 83 Other Practitioner Identification Required 84 Remarks Not Required 85 Provider Representative Required 86 Date Required 129 P age

131 3.2 SAMPLE UB-04 CLAIM FORM 130 P age

132 DATA ELEMENTS FOR CLAIMS SUBMISSION 1500 DATA ELEMENTS FOR SUBMISSION OF CLAIMS FOR PAPER CLAIMS Note: EDI Requirements Must be Followed for Electronic Claims Submission Field # Description Requirements 1 Insurance Type Required 1a Insured Identification Number WVFH Member Identification Number Required (10-digit MA Recipient Number acceptable for Electronic Claims) 2 Patient s Name Required 3 Patient s Birth Date Required 4 Insured s Name Required 5 Patient s Address Required 6 Patient Relationship to Insured Required 7 Insured s Address Required 8 Patient Status Required 9 Other Insured s Name Required, If Applicable 9a Other Insured s Policy or Group Number Required, If Applicable 9b Other Insured s Date of Birth, Sex Required, If Applicable 9c Employer s Name or School Name Required, If Applicable 9d Insurance Plan Name or Program Name Required, If Applicable Is Patient Condition Related to: 10 a. Employment Auto accident Required, If Applicable b. Other accident 10d Reserved for Local Use Not Required (see instructions for EPSDT claims instructions) 11 Insured s Policy Group or FECA Number Required 11a Insured s Date of Birth, Sex Required, If Applicable 11b Employer s Name or School Name Required, If Applicable 11c Insurance Plan Name or Program Name Required, If Applicable 11d Is There Another Health Benefit Plan? Required, If Applicable 12 Patient or Authorized Person s Signature Required 13 Insured s or Authorized Person s Signature Required 14 Date of Current: Illness OR Injury OR Pregnancy Required, If Applicable 15 If Patient has had Same or Similar Illness, Give First Date Not Required 16 Dates Patient Unable to Work in Current Occupation Required, If Applicable 17 Name of Referring Practitioner or Other Source Required 17a Identification Number of Referring Practitioner Not Required 18 Hospitalization Dates Related to Current Services Required, If Applicable 19 Reserved for Local Use Not Required 20 Outside Lab Not Required 21 Diagnosis or Nature of Illness or Injury Required 22 Medical Resubmission Code Not Required 23 Prior Authorization Number Not Required Continued on next page 131 P age

133 DATA ELEMENTS FOR CLAIMS SUBMISSION, Continued Field # Description Requirements 24a Date(s) of Service Required 24b Place of Service Required 24c Type of Service Not Required 24d Procedures, Services, or Supplies CPT/HCPCS/Modifier Required 24e Diagnosis Code Required 24f Charges Required 24g Days or Units Required 24h EPSDT Family Plan Not Required (see instructions for EPSDT claims submissions) 24i EMG Not Required 24j COB Not Required for WVFH Primary Claims 24k Reserved for Local Use Not Required 25 Federal Tax Identification Number Required 26 Patient Account Number Not Required, but WVFH includes payment information when present to assist with reconciliation in provider records 27 Accept Assignment Not Required 28 Total Charge Required 29 Amount Paid Not Required 30 Balance Due Not Required 31 Signature of Practitioner or Supplier including degrees WVFH Individual Practitioner Name and or credentials Date Required 32 Name and Address of Facility Where Services were Rendered Name and Address Required 33 Practitioner s, Supplier s Billing Name, Address, Zip Code and Phone Number WVFH Vendor Name, Address, and Number Required 132 P age

134 3.2 SAMPLE 1500 CLAIM FORM 133 P age

135 CHAPTER 3: POLICIES AND PROCEDURES UNIT 3: REIMBURSEMENT IN THIS UNIT TOPIC SEE PAGE Introduction 135 Facility Providers 136 Physicians and Other Providers 138 Rate Changes 141 Directed Payments to Certain Qualified Providers P age

136 3.3 INTRODUCTION Overview West Virginia Family Health (WVFH) will reimburse contracted network providers for covered services rendered to the West Virginia Medicaid population. Reimbursements to network providers for billed and covered claims will occur on a weekly basis via electronic funds transfer (EFT). This unit provides an overview of the various types of reimbursement methodologies utilized by the Bureau for Medical Services (BMS) and emulated by Highmark West Virginia. In some cases, the network agreement itself includes the detailed components of the pricing methodology as well as the actual payment rates. Questions regarding specific reimbursement methods or rates for WVFH network providers should be directed to the Office of Provider Contracting and Reimbursement of Highmark West Virginia. BMS Reimbursement Hold Harmless BMS is not liable or responsible for payment of covered services rendered to Members pursuant to provider agreement. 135 P age

137 3.3 FACILITY PROVIDERS Introduction The reimbursement methodologies for the various facility and organizational providers with which Highmark Blue Cross Blue Shield West Virginia ( Highmark West Virginia ) contracts on behalf of the West Virginia Family Health (WVFH) are summarized below. Contracted hospital rates such as DRGs (Diagnosis-Related Groups), Per Diems, Case Rates, and Percent of Charge are based upon the current effective Bureau of Medical Services (BMS) method and rate with an additional five percent (5%) included. Hospital inpatient care services WVFH reimburses the current Bureau of Medical Services (BMS) effective rate of reimbursement for each inpatient discharged from an acute care hospital by the DRG classification system. The DRGs are updated annually based on BMS review and recalculation using adjustment/severity factors applicable to certain types of admissions. WVFH follows BMS reimbursement methodology by applying the special prospective payment rules to community hospitals. Psychiatric, rehabilitations, and rural primary care hospitals are reimbursed on a cost-related basis. The current effective BMS cost-related rate is increased by five percent (5%) and updated annually. If a member is confined to an inpatient care facility on the effective date for initial enrollment with WVFH coverage of inpatient facility charges (including charges at a transfer facility if the member is transferred during the stay or within the facility) will be the responsibility of BMS until the member is discharged. WVFH is responsible for all covered services provided on or after the effective date of WVFH enrollment including but not limited to emergency transportation, professional fees during the inpatient stay, and outpatient care. For a WVFH member receiving inpatient care at the time of disenrollment from WVFH, coverage of inpatient facility charges (including charges to a transfer facility if the member is transferred during the stay or within the facility) provided after the effective date of disenrollment will be the responsibility of WVFH until the member is discharged. Coverage of all other covered services (included by not limited to emergency transportation, professional fees during the inpatient stay and outpatient care) during the inpatient stay will be the responsibility of BMS as of the effective date of disenrollment from WVFH. WVFH is not responsible for the inpatient facility charges for a member who is no longer eligible for Medicaid coverage as of the first of the month following the loss of Medicaid coverage. Continued on next page 136 P age

138 3.3 FACILITY PROVIDERS, Continued Hospital outpatient services WVFH reimburses hospital outpatient services based on the current prevailing methodology utilized by BMS. Emergency Room and Observation are reimbursed using the BMS Medicaid fee schedule. Surgeries and recovery are reimbursed at the set BMS fee amount multiplied by the total unit of time. Radiology, physical therapy, and occupational therapy services, as well as cardiac and pulmonary rehabilitation, are reimbursed in the same manner as BMS reimbursement. Critical Access Hospital services are reimbursed at the current effective BMS encounter rate as set by the Office of Audits or by fee for service. PROVIDER TYPE Acute Inpatient Outpatient Critical Access Inpatient Outpatient METHOD(S) OF PRICING DRG E/R, Recovery and Observation based on Fee Schedule x units, Radiology, PT and OCC Therapies based on BMS RBRVS Cost Based Per Diem O/P Encounter Rate set by Office of Audits or Fee for Service* Cost basis for other service types High-cost drugs invoice billing process The Bureau for Medical Services (BMS) has outlined the process that will be used to determine the reimbursement for high-cost drugs that are invoiced by hospitals. This process applies to any claims with services on the BMS list that are marked: Paper Claim. Providers are required to submit a copy of the invoice which includes the NDC billed. Please Note: These codes are not priced on the Fee Table. Providers may bill the entire claim electronically, and then submit a copy of the UB with the invoice and any applicable EOBs from other carriers for the additional drug processing to the following address: West Virginia Family Health 444 Liberty Avenue, Suite 2100 Pittsburgh, PA ATTN: Invoice Claim Processing Payment will be made based on the unit price times the number of units billed on the claim. If you have any questions, please contact WVFH Provider Services at P age

139 3.3 PHYSICIANS AND OTHER PROVIDERS Overview Physicians and other providers are generally reimbursed at the prevailing Bureau of Medical Services (BMS) Resource Based Relative Value Scale (RBRVS) fee schedule multiplied by the BMS conversion factor. Based on BMS treatment and reimbursement of professional providers, the following types of providers are reimbursed under the effective BMS RBRVS fee schedule: Physicians (including doctors of medicine and osteopathy and Physician Assistants working under their supervision) Limited licensed practitioners (including doctors of optometry, podiatry, dental surgery and dental medicine: oral and maxillofacial surgery, and chiropractors) Independently practicing Physical Therapists and Occupational Therapists for outpatient services only Suppliers of the technical component of radiology or diagnostic services Family and Pediatric nurse practitioners Nurse Midwives Certified Registered Nurse Anesthetists ANCILLARY PROVIDERS PROVIDER TYPE METHOD(S) OF PRICING Ambulance - Ground BMS Medicaid Fee Schedule, Separate rates for ground/air Ambulatory Surgery Centers BMS Medicaid Fee Schedule Durable Medical Equipment (A, E, K, L Codes) BMS Medicaid Fee Schedule Hearing Aid Facilities BMS Medicaid Fee Schedule Home Health Agencies Per Visit, BMS Medicaid Fee Schedule Home Infusion Therapy BMS Fee schedule for per diem services Hospice BMS Per Diem Renal Dialysis BMS Global Fee Skilled Nursing Facilities BMS Per Diem PHYSICIAN SERVICES AND OTHER PROFESSIONALS PROVIDER TYPE METHOD(S) OF PRICING Medical WV RBRVS x BMS conversion factor Maternity WV RBRVS x BMS conversion factor and Medicaid Fee Schedule Lab BMS Fee Schedule, Clinical Labs BMS RBRVS Fee Schedule Dental WV RBRVS x conversion factor for dental surgeries only Vision BMS Medicaid Fee Schedule Anesthesiology BMS Conversion Factor x sum of base + time units Continued on next page 138 P age

140 3.3 PHYSICIANS AND OTHER PROVIDERS, Continued Dental services The West Virginia RBRVS fee schedule multiplied by the BMS conversion factor is used to pay for dental surgeries covered when billed by a physician. Other covered dental services are paid using the BMS fee schedule which establishes a fee for each American Dental Association (ADA) procedure code. In each case, the Highmark West Virginia reimbursement is based on the lower of the amount of charges for the service or the fee schedule amount. Durable medical equipment (DME) Durable medical equipment (DME), medical supplies, and orthotic and prosthetic devices are reimbursed in alignment with BMS classifications. A separate method applies to each class and the payment is based upon the rental or purchase basis of the item. DME payment is based on the lower of the amount the supplier charges for the item or the fee schedule amount, and is applicable to payments for repairs and maintenance. Free-standing ambulatory surgical centers Reimbursement for covered services performed in a free standing ambulatory surgical setting follows the BMS reimbursement methodology by percent of applicable fee schedule. Home health services The current effective BMS fee schedule is the basis used to determine the amount to be paid for skilled home health care for the following covered services: nursing care, rehabilitation services, home health aide services, and medical social services. Each visit for home health care is considered one unit of payment. Hospice services Hospital hospice and home hospice reimbursements are based on the current Medicaid fee schedule. Nursing home hospice is reimbursed a percentage of the patient specific nursing home rate. Laboratory services WVFH reimburses for covered laboratory services at the effective Medicaid fee schedules, with the exception of hospital-based laboratories performing such tests for their own inpatients. Payment for laboratory services is based on the lower of the effective Medicaid fee schedule or the amount the network provider charges for the service. Certain tests exempt from Medicaid s fee schedule for clinical diagnostic laboratory services are paid under the RBRVS fee schedule. Out of Network WVFH considers reimbursement to out-of-network providers when the services cannot be provided by an in-network provider and the referring WVFH participating provider has obtained a prior-authorization. All out-of-network services (other than emergency services) require prior authorization by the WVFH UM department before services are rendered. WVFH members admitted to an outof-network facility will be transferred when the patient is medically stable for 139 P age

141 transfer ad provision for care is available at an in-network facility. If an authorization exists at the time of claim adjudication the claim will be processed for payment. All out-of-network claims are subject to the same fee and payment regulations as in-network providers. Preventable Serious Adverse Event (PSAE) The Patient Protection and Affordable Care Act (ACA) required the United States Department of Health and Human Services (HHS) to promulgate regulations that prohibit payment by State Medicaid Programs for provider preventable conditions (PPCs) which encompasses health care-acquired conditions (HCACs). In accordance a retrospective review of claims occurs monthly by WVFH s Quality Improvement (QI) department. For claims identified with charges resulting from a Preventable Serious Adverse Event (PSAE), a determination is made through medical review as to the specific charge or charges that are considered a preventable serious adverse situation. Charges deemed not medically necessary and determined to relate to a PSAE are non-covered services. All impacted charges are reversed and payment retracted from the provider. 140 P age

142 3.3 RATE CHANGES Policy for rate changes Rates for covered inpatient and outpatient services shall remain fixed until such time that Bureau of Medical Services (BMS) changes its reimbursement to the contracted network provider or implements an alternative methodology for reimbursement. WVFH will implement any rate changes adopted by the Department within thirty (30) calendar days of notification of the rate change. WVFH will pay the new rate for claims not yet paid with a date of service on or after the effective date of change. WVFH will reprocess any claims paid between the notification date and the system load date to the updated rate. This provision does not apply to payments made to CAH under Article III, or payments made to FQHCs/RHCs per Article III, In regard to Hospital inpatient and/or outpatient rates, including cost-based rate changes, it is the responsibility of the Hospital to notify Highmark West Virginia of any such changes. Once the Hospital notifies Highmark West Virginia, Highmark West Virginia shall then update the Hospital s current outpatient rates by the BMS percentage change with an effective date fifteen (15) business days after the Hospital s notification to Highmark West Virginia. Previously processed claims will not be adjusted due to any retroactive change implemented by BMS. 141 P age

143 3.3 DIRECTED PAYMENTS TO CERTAIN QUALIFIED PROVIDERS Directed Payments WVFH must reimburse Qualified Providers at the levels directed by the Bureau of Medical Services (BMS). BMS must provide the levels for the Directed Payments to WVFH on the State Fiscal Year basis. Qualified Providers include: 1. A non-state, but government owned facility such as a county or city hospital; 2. University Practice Plans; 3. Public safety net hospitals; and 4. Private hospitals, except for the critical access hospitals. 142 P age

144 3.3 DIRECTED PAYMENTS TO CERTAIN QUALIFIED PROVIDERS APMs BMS supports a value based health care system where member experience and population health are improved, the trajectory of health care cost is contained through aligned incentives with the managed care organizations and provider partners, and there is commitment to continuous quality improvement and learning. WVFH will be implementing Alternate Payment Models (APMs) that shift from fee-for-service reimbursement to reimbursement models that reward improved delivery of care. BMS is setting targets for each MCO to have 10% of their members enrolled in APMS in 2018 and intends to increase this target for future years. As WVFH implements APMs, information will be provided in this section. APMs include, but are not limited to: 1. Primary care incentives 2. Pay for performance 3. Shared savings arrangements 4. Risk sharing arrangements 5. Episodes of care/bundled payments 6. Capitation payments with performance and quality requirements 143 P age

145 CHAPTER 3: POLICIES AND PROCEDURES UNIT 4: MEMBER AND PROVIDER DISPUTES IN THIS UNIT TOPIC SEE PAGE Provider Appeals 145 Provider Disputes 147 Member Grievance Process 148 Informal Grievances 148 Formal Grievances 149 External Grievance Review 149 Member Appeals 150 Provider Initiated Member Grievances or Appeals 155 Provider Complaints P age

146 3.4 PROVIDER APPEALS Overview Providers who disagree with a decision to deny authorization or payment have the right to appeal the decision. WVFH offers providers: 1) An informal and formal appeals process to request reversal of a denial by WVFH; and 2) An informal and formal dispute process for expressing dissatisfaction with WVFH decisions which directly impacts the provider. Types of provider appeals A provider appeal is a request from a Provider for reversal of a denial by WVFH in regard to three major types of issues: 1. Provider credentialing denial by WVFH. Please see Chapter 2, Unit 2: Network Credentialing Procedures of the Highmark Blue Shield Office Manual for more information (also available on the Highmark West Virginia Provider Resource Center under Administrative Reference Materials). 2. Claim Denials. Claims denied by WVFH for Network providers. This includes payment denied for services already rendered by the Network provider to the member. a. Informal Process. Claims that need to be reviewed based upon administrative, policy, or processing issues can be discussed with a Provider Services Representative. For inquiries received in the mail, Claims Review Representatives evaluate whether the documentation attached to the claim is sufficient to allow it to be reconsidered. Inquiries received in the mail that qualify for adjustments will be reprocessed, and claim information will appear on subsequent EOPs. Claims that do not qualify for reconsideration will be responded to via a letter. All review requests must be received within 120 days of the initial EOP. Informal appeals will completed within thirty (30) days of receipt. b. Formal Process. If the provider does not agree with the informal appeal decision, the provider can request a formal appeal. The provider must submit a written request for a second level appeal or request additional review on an already denied. The Provider Appeal/Dispute Committee will review all formal appeals and make a determination within sixty (60) days. The provider will be informed of the formal appeal decision in writing. The formal appeal decision is final and binding. For more information regarding Provider Appeals, please see Chapter 4, Unit 4: Denials, Grievances, and Appeals of the Highmark Blue Shield Office Manual. All written appeals must be sent to: West Virginia Family Health Attention: Provider Appeals P.O. Box Pittsburgh, PA Continued on next page 145 P age

147 3.4 PROVIDER APPEALS, Continued Types of provider appeals (continued) 3. Termination of Network Provider Agreement by Highmark West Virginia or West Virginia Family Health. For more information regarding corrective action, termination, and appeals, please see Chapter 2, Unit 2: Network Credentialing Procedures of the Highmark Blue Shield Office Manual (also available on the Highmark West Virginia Provider Resource Center under Administrative Reference Materials). Note: The above process for claim denials is the mechanism for all providers, regardless of participation status, to appeal denied payment (post-service) for services rendered to WVFH members. This process will be intended to afford providers with the opportunity to address issues regarding payment only. Appeals for services that have not yet been provided will follow the Member Grievance or Complaint processes. The provider will have an option for an informal and formal review of the denied payment. 146 P age

148 3.4 PROVIDER DISPUTES Definition A provider dispute is when a provider expresses dissatisfaction with a Health Plan decision that directly impacts the provider. This does not include decisions concerning Medical Necessity. Dispute processes Following are the informal and formal dispute processes: Informal Provider Dispute Process. When a written Provider Dispute is received, it will be forwarded to the appropriate department within WVFH for resolution. The dispute will be researched and responded to within fortyfive (45) days of receipt. This initial response is considered the informal settlement process for the dispute. Formal Provider Dispute Process. If a provider disagrees with our initial response and sends in an additional written inquiry within sixty (60) days of incident being disputed, the Provider Dispute/Appeals Committee will hear all formal Provider Disputes and make a determination. Once received, dispute will be reviewed, and a decision will be rendered within sixty (60) days after receipt. Provider Disputes can be requested verbally by contacting WVFH s Provider Service Department. 147 P age

149 3.4 MEMBER GRIEVANCE PROCESS Overview WVFH provides an informal and a formal grievance (complaint) process for its members. Members may file grievances with WVFH regarding issues such as services denied, quality of care, service complaints and payment. A member may choose either process when filing a grievance. A provider may file a grievance on the member s behalf; however, the provider must be officially appointed as the member s representative to do so (see Provider Initiated Member Grievances or Appeals later in this unit for more information). WVFH will require that documentation is submitted to demonstrate said appointment prior to initiating grievance proceedings. Informal grievances An informal grievance is an oral expression of dissatisfaction other than those subject to appeal. The filing limit for an informal grievance is within ninety (90) days of the date of the occurrence giving rise to the matter at issue in the grievance. An informal grievance maybe filed orally by the Member or Member s appointed representative by calling WVFH s toll-free Member Services number at (TTY/TDD 711or ). After receiving an oral request, WVFH will send an acknowledgement letter within five (5) working days which will advise the Member or Member s appointed representative of the following: The Member may appoint a representative to act on his or her behalf. The Member or Member s appointed representative may submit additional information in writing or orally. The Member or Member s appointed representative may review all documentation regarding the formal grievance upon request free of charge. The Member s right to meet with WVFH during the formal grievance process. Informal grievances are resolved within thirty (30) days of receipt, and a letter explaining the outcome is mailed to the Member and/or Member s appointed representative. 148 P age

150 3.4 MEMBER GRIEVANCE PROCESS, Continued Formal grievances Formal grievances are written expressions of dissatisfaction other than those subject to appeal. If a Member or Member s appointed representative is not satisfied with the outcome of an informal grievance, a written formal grievance may be filed within one (1) year of the date of occurrence or within ninety (90) das from the date on the informal grievance decision letter. WVFH will accept oral or written formal grievances; however, an oral grievance will not be processed until the Member or Member s appointed representative s signature is obtained. If an oral formal grievance is received, WVFH will record the formal grievance on paper and mail to Member or Member s appointed representative for signature along with a self-addressed, postage-paid envelope for Member or Member s appointed representative to return. After receiving a written request, WVFH will send an acknowledgement letter within five (5) working days which will advise the Member or Member s appointed representative of the following: The Member may appoint a representative to act on his or her behalf The Member or Member s appointed representative may submit additional information in writing or orally. The Member or Member s appointed representative may review all documentation regarding the formal grievance upon request free of charge. The Member s right to meet with WVFH during the formal grievance process. Formal grievances will be processed within forty-five (45) days of the receipt of the written request/signed grievance. A letter explaining the outcome is then mailed to the Member or Member s appointed representative. External grievance review If a Member or Member s appointed representative is not satisfied upon the exhaustion of the formal grievance review process, a request may be submitted, in writing, to the Insurance Commissioner by sending the grievance appeal to: The Office of the Insurance Commissioner P.O. Box Charleston, WV P age

151 3.4 MEMBER APPEALS Overview An appeal is defined as a request for a review of WVFH s action to deny or limit authorization or payment (in whole or in part) for health care services including: New authorizations Previously authorized services A reduction, suspension, or termination of a previously authorized service WVFH s failure to provide services in a timely manner WVFH s failure to resolve grievances or appeals within the timeframe specified WVFH s denial of a request by a member to receive out-of-network services when the member resides in a rural area with only one managed care organization. Appeals arising out of complaints (when applicable). The Member must file an appeal within ninety (90) days from the date of the incident complained of or the date the Member receives the Notice of Action. Services during appeal process If the Member or Member s appointed representative files an Appeal to dispute a decision to terminate, suspend, or reduce a previously authorized course of treatment that was ordered by an authorized provider where the original period covered by the original authorization has not expired and the Member requests an extension of benefits, the Member must continue to receive the services if the Appeal is submitted within ten (10) days from the mail date on the written Notice of Action letter. The benefits shall be continued or reinstated until the Member or Member s representative withdraws the appeal, ten (10) days after WVFH mails the resolution of the appeal unless the Member has requested a State fair hearing within that ten (10) day time frame, or the time period or service limits of a previously authorized service have been met. If services are continued during the appeal process and WVFH upholds its decision to terminate, suspend, or reduce, the member may be liable for payment of the services received through continuity. WVFH letter to acknowledge receipt of an appeal Within five (5) working days of the receipt of an appeal, WVFH will send an acknowledgement letter to the Member, the Member s appointed representative, and the provider. The letter will include the following information: The Member, Member s appointed representative, or provider that filed on the Member s behalf has the right to review information related to the appeal upon request (free of charge); Continued on next page 150 P age

152 3.4 MEMBER APPEALS, Continued WVFH letter to acknowledge receipt of an appeal (continued) The Member, Member s appointed representative, or provider that filed on the Member s behalf can submit additional information to be considered by the plan; and The Member or Member s appointed representative has the right to request the aid of a WVFH staff member who has not been involved in the matter under review to assist them through the appeal process (free of charge). WVFH review and decision notice A licensed physician who has not been involved in any previous level of review or decision making on the issue of your appeal and who has clinical experience in treating your condition will review your appeal. WVFH will commence its review, arrive at its decision, and issue a written decision notice within thirty (30) days of receiving the appeal. The time frame for a decision may be extended up to fourteen (14) days at the request of the Member, or by WVFH if additional information is necessary and the delay is in the Member s interest. If WVFH extends the time frame, WVFH will send the Member a written notice of the reason for the delay. A written notice of the appeal decision notifying the Member, Member s appointed representative, or provider who filed on behalf of the member will include the disposition of the appeal including the following: the action taken or intended to be taken; the reasons for the action including the benefit provision, guideline, protocol, or other similar criterion on which the decision is based; the right and the procedure to request a state fair hearing (must be filed within ninety (90) days from the mail date on the appeal decision letter); the right to receive continuation of benefits while the hearing is pending; how to make a request for continuation of benefits; the potential Member liability for the cost of continuation benefits if the State Fair Hearing upholds WVFH s decision. Expedited appeals The Member, Member s representative with written consent of the Member, or health care provider can file an Expedited Appeal orally with WVFH by contacting Member Services at or in writing at: West Virginia Family Health Attention: Member Appeals P.O. Box Pittsburgh, PA Continued on next page 151 P age

153 3.4 MEMBER APPEALS, Continued Expedited appeals (continued) The Expedited Appeal process is provided for use in instances when the Member s life or health or ability to attain, maintain, or regain maximum function would be placed in jeopardy by the delay occasioned by the standard thirty (30) day review process. The Member s physician must provide written certification of the need to expedite the process. The certification must include the clinical rationale and facts to support the physician s opinion. If a physician certification is not received, a WVFH physician will determine if the request is in need of expeditious resolution. If the Member or Member s appointed representative files an expedited appeal to dispute a decision to terminate, suspend, or reduce a previously authorized course of treatment that was ordered by an authorized provider where the original period covered by the original authorization has not expired and the Member requests an extension of benefits, the Member must continue to receive the services if the appeal is submitted within ten (10) days from the mail date on the written Notice of Action letter. The benefits shall be continued or reinstated until the Member or Member s representative withdraws the appeal, ten (10) days after WVFH mails the resolution of the appeal unless the Member has requested an expedited appeal within that ten (10) day time frame, or the time period or service limits of a previously authorized service have been met. If services are continued during the expedited appeal process and WVFH upholds its decision to terminate, suspend, or reduce, the member may be liable for payment of the services received through continuity. The expedited appeal request will be committed to writing and will be reviewed under the same requirements as the formal grievance process previously described with the following exceptions: WVFH will make reasonable efforts to provide oral notice of the disposition of the expedited review to the Member, Member s appointed representative and the provider involved in the expedite within 72 hours of receiving the request for expedite. The 72 hour time frame may be extended by up to 14 days upon the Member s request or if WVFH shows that additional information is required and that the delay is in the best interest of the Member. If the time frame for resolving an expedited appeal is extended for any reason other than the Member s request, WVFH shall give the Member written notice of the reason for the delay. It is the responsibility of the Member, the Member s appointed representative, or the appealing provider to submit information to WVFH within the time constraints of the expedited appeal process. Continued on next page 152 P age

154 3.4 MEMBER APPEALS, Continued Expedited appeals (continued) WVFH will ensure that punitive action is not taken against a provider who either requests expedited resolution of an appeal or supports a Member s request for an expedited review. A written notice will follow that explains the rationale for the decision, including any clinical rationale and the procedure for obtaining a State Fair Hearing. The decision notice will follow the same guidelines as the standard appeal follows. State Fair Hearing A Member must exhaust the appeals process prior to filing a request for a State Fair Hearing. A State Fair Hearing will be provided by the State if WVFH has denied, terminated, or reduced services or has failed to give a Member timely service. A request for a State Fair Hearing can be made orally, in writing, or by completing a Request for Hearing form at the Member s local Department of Health and Human Resource (DHHR) office. Members must request a State Fair Hearing within ninety (90) days from the date on the appeal decision letter. State Fair Hearing requests should be sent to: Bureau for Medical Services Office of Legal Services 350 Capitol St., Room 251 Charleston, WV If the Member or Member s appointed representative files a State Fair Hearing to dispute a decision to terminate, suspend, or reduce a previously authorized course of treatment that was order by an authorized provider where the original period covered by the original authorization has not expired and the Member requests an extension of benefits, the Member must continue to receive the services if the request for State Fair Hearing is submitted within ten (10) days from the mail date on the written appeal decision letter. The benefits shall be continued or reinstated until the Member or Member s appointed representative withdraws the State Fair Hearing, ten (10) days after WVFH mails the resolution of the appeal unless the Member has requested a State fair hearing within that ten (10) day timeframe, or the time period or service limits of a previously authorized service have been met. If services are continued during the State Fair Hearing process and the State upholds WVFH s decision to terminate, suspend, or reduce, the Member may be liable for payment of the services received through continuity. 153 P age

155 3.4 PROVIDER INITIATED MEMBER GRIEVANCES OR APPEALS Overview The Member has the right to ask any person (family, friend, relative, attorney, provider, etc.) to act as a representative during the grievance or appeal process. This person is referred to as the Member s representative. If the representative is a health care provider, the provider must secure and provide to WVFH the Member s written consent to do so. If the Member is a minor or legally incompetent, the provider must submit written consent of the parent, guardian, or legally appointed representative in order to pursue a grievance or appeal. It is important to note that the Member may rescind consent at any time. This process does not need followed if an expedited appeal is requested. Member consent requirements Providers may request the Member s written consent to appeal prior to treatment, but it cannot be a requirement for treatment to be provided. In addition, Medicaid Members may not be billed or balance billed for covered services at any time. The Member s consent is automatically rescinded if the provider fails to pursue the grievance or appeal and the Member may continue the grievance or appeal at that point in the process. An acceptable consent document must contain all of the following components: The Member s name; The Member s address; The Member s identification number; If the Member is a minor or legally incompetent, the name, address, and relationship to the Member of the person who consents for the Member; The name, address and identification number of the provider to whom the Member or representative is granting consent; The name and address of the plan to whom the Member or representative is providing consent; An explanation of the specific service for which coverage was provided and/or denied to which the consent applies. The following statements must also be included in the consent document: The Member or the Member s representative may not submit a grievance concerning the services listed in this consent form unless the Member or the Member s legal representative rescinds consent in writing. The Member or the Member s legal representative has the right to rescind consent at any time during the grievance or appeal process. Continued on next page 154 P age

156 3.4 PROVIDER INITIATED MEMBER GRIEVANCES OR APPEALS, Continued Member consent requirements (continued) The consent of the Member or the Member s legal representative is automatically rescinded if the provider fails to file a grievance or fails to continue to prosecute the grievance or appeal through the second level review process. The Member or the Member s legal representative, if the Member is a minor or is legally incompetent, has read, or has been read this consent form, and has had it explained to his or her satisfaction. The Member or the Member s legal representative understands the information in the Member s consent form. The document must also contain the dated signature of the Member or the Member s legal representative if the Member is a minor or is legally incompetent as well as the dated signature of a witness. The Member may rescind the consent at any time during the grievance or appeal process. If consent is rescinded, the Member may continue the process at the point in the process at which consent was rescinded. The Member may not file a separate grievance or appeal. A Member who has already filed a grievance or appeal may choose to authorize a provider to pursue the grievance or appeal process at any point during the process. A Member s appointed representative carries all the rights conferred upon the Member. Provider Complaints West Virginia Family Health has created a Provider Complaint system for participating and non-participating providers to raise issues with WVFH policies, procedures and administrative functions. Complaints will be investigated and the details of the findings and disposition will be communicated back in writing to the provider within 30 days of receipt. If additional time is needed to resolve WVFH will provide status updates to the provider as applicable. Any misdirected submissions, including but not limited to Administrative Reviews or Clinical Appeals, into the Provider Complaint system will be routed to the appropriate department. The provider will be advised of the redirection and educated on proper handling and contact details of the appropriate department for future reference. All network providers are required to be NaviNet-enabled. Providers are expected to use this tool to access the Provider complaint Messaging Centre. All nonparticipating providers will be directed to complete the WVFH Non- Participating Provider Complaint Form available on the WVFH website under Provider Forms & Reference Materials. The form may be submitted to ProviderComplaints@GatewayHealthPlan.com or faxed to P age

157 CHAPTER 4: HEALTH CARE MANAGEMENT UNIT 1: REFERRALS IN THIS UNIT TOPIC SEE PAGE General Information 157 Voice Activated Referral 159 Paper Referrals 163 Referrals for Specific Services 165 Out-of-Plan Referrals 165 Referrals for Second Opinions 165 Referrals for Surgical Second Opinions 165 Specialty Care Practitioners 165 Renal Dialysis Services 166 Audiology and Speech Therapy 166 Self-Referral P age

158 4.1 GENERAL INFORMATION Introduction Referrals and authorizations are necessary in order to preserve the PCP s gatekeeper relationship with the patient. Both processes allow West Virginia Family Health (WVFH) to manage the care of its member population. The major differences between referrals and authorizations are highlighted below: Referrals allow the PCP to approve specialty services for members on their panel. Authorizations allow WVFH to confirm eligibility of the member prior to receiving services; to assess the medical necessity and appropriateness of care; to establish the appropriate site for care; and to identify those members who would benefit from case management. Referrals will be discussed in this unit. For authorization information, please see this manual s Chapter 4, Unit 2: Authorizations. Self-referrals In certain instances, members do not require a referral from the PCP to see a Network specialty care practitioner. For the following services, members can selfrefer: OB/GYN Services Family Planning Services (Family Planning services do not have to be rendered by a network provider) Dental services provided by a network dentist Routine vision Chiropractic services (an authorization must be obtained by the chiropractic office, including the initial evaluation Mental health/substance abuse services Determining if a service requires a referral or authorization Some services, such as hospital admissions, require authorization by the WVFH Utilization Management Department. To authorize a service, please call WVFH s Utilization Management Department at To determine which services require a referral or authorization, please refer to WVFH s Quick Reference Guide for Referrals and Authorizations. This guide is also available in this manual s Appendix. Continued on next page 157 P age

159 4.1 GENERAL INFORMATION, Continued Referring to Network providers When a PCP determines that a member requires medical services or treatment outside of the PCP s office, the PCP must issue a referral to a Network facility or specialty care practitioner. If services are performed in a hospital setting, the referral should be issued to the hospital s provider identification number. PCPs may not issue referrals to other PCPs. 158 P age

160 4.1 VOICE ACTIVATED REFERRAL Voice activated referral WVFH s Digital Voice Assistance (DIVA) system may be used by PCPs to issue a referral, and by specialty care practitioners and hospitals to verify and review a referral. To use the system, call , and please follow the prompts, or use the guide below for a quick reference. Do not use this system to refer to a dental provider. DIVA Quick Referral Entry Guide If you are a new DIVA user, we suggest for your initial try at entering a referral that you use the detailed Referral Entry instructions below or in the DIVA Quick Referral Entry Guide. You ll quickly find it only takes seconds to generate a DIVA referral. This guide is also available in this manual s Appendix. IMPORTANT! DIVA is only for referrals from PCPs to specialists (independent or at hospital clinics). Authorization is still required for some services. Specialists and hospitals may only review referrals. Before you begin To issue a Referral, you will need: Provider ID Number ( Practice Number ) Member ID Number Specialist/Hospital Provider ID Number ( Practice Number ) for the referred provider Type of referral and number of visits The system will provide a referral number and provides an option to fax a confirmation of the referral information to the specialist/hospital. Continued on next page 159 P age

161 4.1 VOICE ACTIVATED REFERRAL, Continued To issue a referral After dialing into DIVA at , first Press 1 to retrieve information regarding West Virginia members, and then Press 2 to enter a new referral. Follow the prompts below: STEP ACTION 1 Provider Identification Number? Enter your group provider number. 2 Member Identification Number? Enter the member s 8 digit ID number (as it appears on the member s ID card). 3 Specialist/Hospital Provider Identification Number? Enter the group provider number of the specialist hospital to which you wish to refer the member. Finish by pressing the # key. 4 (pause) Verification of Identification Numbers 5 Type of Referral o Press 1 to enter a general referral for three visits within the next 90 days. o Press 2 to enter a referral for allergy or pain management services for nine visits within the next 90 day. Please enter the beginning date for the referral. Referrals can be backdated 30 calendar days. Enter the two digit month, the two digit day, and the four digit year. Press 1 if the repeated date is correct. Press 2 if the repeated date is incorrect. Press the * key to begin again. 6 Save Referral? o Press 1 to save the referral (wait for referral ID number). o Press 2 to discard the referral. ADDITIONAL INSTRUCTIONS: Press 1 to repeat the referral number Press 2 to enter a new referral for the same PCP Press 3 to enter a new referral for a different PCP Press 4 to fax a referral (see options below*) Press 5 to return to the main menu Press 6 if you are finished Press 9 to hear this menu again Press 0 to be connected to a Provider Services Representative *If you chose 4: To fax a referral, choose one of the following options: o Press 1 to send a fax to the PCP only (see options below**) o Press 2 to send a fax to the specialist/hospital only (see options below**) Continued on next page 160 P age

162 4.1 VOICE ACTIVATED REFERRAL, Continued To issue a referral (continued) o Press 3 to send a fax to both the PCP (see options below**) o Press 4 to return to the main menu without sending a fax o Press 9 to hear this menu again o Press # to return to the previous menu **If you chose 1, 2, or 3: To send a fax, choose one of the following options: Press 1 to use the fax number stored in the database Press 2 to enter a fax number (allows you to enter any fax number) Press # to return to the previous menu To verify or review a referral After dialing into DIVA at , first Press 1 to retrieve information regarding West Virginia members, and then Press 3 to review an existing referral. Follow the prompts below: STEP ACTION 1 Provider Type? o Press 1 if you wish to enter a PCP ID Number o Press 2 if you wish to enter a specialist/hospital ID Number 2 Provider Number? Enter your group provider identification number. 3 Member ID Number? Enter the member s 8-digit WVFH ID number (as it appears on the member s ID card). 4 (pause) Referral Information If there is a match, the following information will be provided: PCP ID Number; Member ID Number; Specialist/Hospital ID Number; Referral Case Number; Effective Date; Expiration Date; Number of Visits Approved Playback Options: Press 1 to play the referral information again Press 2 to check for subsequent referrals Press 3 to check for a referral using the same PCP Press 4 to check for a referral using a different PCP or specialist Press 5 to fax a list of reviewed referrals (see options below*) Press 6 to return to the main menu Press 7 to exit Press 9 to hear this menu again Press 0 to speak with a Provider Services Representative Continued on next page 161 P age

163 4.1 VOICE ACTIVATED REFERRAL, Continued To verify or review a referral (continued) *If you chose 5: To fax a referral, choose one of the following options: o Press 1 to send a fax to the PCP only (see options below**) o Press 2 to send a fax to the specialist/hospital only (see options below**) o Press 3 to send a fax to both the PCP (see options below**) o Press 4 to return to the main menu without sending a fax o Press 9 to hear this menu again o Press # to return to the previous menu PLEASE NOTE: The number of the practitioner will be reviewed via the automated system if one is found. Please assure that this is the number that you wish to send the fax to. See additional options below for choosing the default fax or entering a new fax number. **If you chose 1, 2, or 3: To send a fax, choose one of the following options: Press 1 to use the fax number stored in the database Press 2 to enter a fax number (allows you to enter any fax number Press # to return to the previous menu NOTE: You may press 0 (zero) followed by the # sign at any time to speak to a Provider Services Representative. If a referral is found that matches the information entered, the system will provide the following information: Provider ID Number Member ID Number Referral Case Number Effective Date and Expiration Date Number of Visits Approved 162 P age

164 4.1 PAPER REFERRALS Overview WVFH understands that there may be instances when a PCP is unable to use DIVA. A downloadable version of the PCP Referral Form is available in the Appendix of this manual and also on the WVFH website at Each time a form is downloaded, it is given a unique referral number. For claims payment purposes, each referral you issue requires a NEW form to be downloaded and printed. Just print, complete, and mail to the address on the form. Prior to completing the form Please use the following procedure prior to completing your downloaded paper referral form: 1. Check your practice s Member List or call WVFH s Digital Voice Assistant to verify the member s eligibility. 2. Assure that the needed service does not require an authorization from WVFH. 3. Select a Network specialist or facility appropriate for the member s medical needs from WVFH s Provider On-line Directory. If an appropriate provider is not listed in the Directory, please call Provider Services for assistance. Instructions for completing the paper referral form Once a Network provider is selected from WVFH s On-Line Directory, the primary care practitioner s (PCP) office completes the following sections of the Referral Form: 1. Primary Care Information: a. Complete the primary care practitioner (PCP) Name, Practice Address, and Telephone Number. b. Fill in the Practice s 7-digit WVFH Provider ID Number. 2. Patient Information a. Complete the Patient s Name. b. Fill in the Member s 8-digit WVFH Member ID Number. Complete the diagnosis and/or complaint field being as specific as possible. The diagnosis can be an ICD-10 (preferred) (or its replacement) code or a written description. 3. Specialty Provider or Facility Information a. SPECIALTY CARE PROVIDER: Complete the Specialist group name and WVFH Provider ID Number for services rendered at office site only. b. FACILITY PROVIDER: Complete the Facility name and WVFH Facility ID Number for services rendered at outpatient facility to allow both facility and practitioner services to be covered. Continued on next page 163 P age

165 4.1 PAPER REFERRALS, Continued Instructions for completing the paper referral form (continued) 4. Referral Services If you are referring a member for services that DO NOT REQUIRE authorization, you can check the appropriate service and specify additional information as requested on the form. 5. PCP Signature The paper referral form must be signed by the member s PCP. If an office staff member completes the referral, the staff member must place their initials after the practitioner s stamp or signature. AN UNSIGNED PAPER REFERRAL FORM IS NOT VALID. 6. Referral Date The Referral Form must be dated. If the Referral Form is not dated, WVFH will date according to receipt date at the claim office. Payment for referral and authorized services is contingent upon the patient being an enrolled WVFH member at the time of the service. 164 P age

166 4.1 REFERRALS FOR SPECIFIC SERVICES Out-of-plan referrals Occasionally, a member may need to see a specialty care practitioner outside of WVFH s provider network. When the need for out-of-plan services arises, the PCP must contact WVFH s Utilization Management Department to obtain an authorization. The Utilization Management Department will review the request and make arrangements for the member to receive the necessary medical services with a specialty care practitioner in collaboration with the recommendations of the PCP. Every effort will be made to locate a specialty care practitioner within an accessible distance to the member. Referrals for second opinions WVFH ensures member access to second opinions. Second opinions may be requested by WVFH, the member, or the PCP. WVFH will provide for a second opinion from a qualified health care provider within the network, or arrange for the member to obtain one outside the network, at no cost to the member. The second opinion specialist must not be in the same practice as the attending physician and must be a Network provider of WVFH. Out of network referrals may be authorized when no Network provider is accessible to the member or when no Network provider can meet the member s needs. Referrals for second surgical opinions Second surgical opinions may be requested by WVFH, the member, or the PCP. When requesting a second surgical opinion consultation, WVFH recommends that you issue a referral to a consulting practitioner who is in a practice other than that of the attending practitioner, or the practitioner who rendered the first opinion and possesses a different tax identification number than the attending practitioner. Specialty care practitioners When a WVFH member schedules an appointment with a specialist, the office should remind the member that a referral from the PCP is needed in order to receive treatment from the specialist, with the exception of a self-referred benefit. Specialty care practitioners should verify the existence of a valid referral through the DIVA System by calling prior to providing treatment. If a paper referral form is utilized, the specialty care practitioner must review the referral form to verify that the form is valid. A valid form is signed by the PCP and has a referral date within the last ninety (90) days. If other services are needed in addition to those authorized by the PCP, a treatment plan must be completed and forwarded to the PCP for authorization. The PCP can then issue additional referrals based upon the recommendations of the specialty care practitioner. Continued on next page 165 P age

167 4.1 REFERRALS FOR SPECIFIC SERVICES, Continued Specialty care practitioners (continued) Since specialists cannot refer members to other specialists, the PCP must refer the member to another specialist. If a specialist recommends that the patient should be seen by another specialty care practitioner, the specialist must contact the PCP, and the PCP may then examine the patient and/or review the consult report prior to referring the patient to another specialist. The only exception to this is for neonatologists who may issue a referral to other Network hospitals and/or specialists for babies discharged from the NICU who require service before seeing their PCP. Referrals should be issued under the baby s WVFH ID Number. If the baby does not have an ID Number, the practitioner should call WVFH s Utilization Management Department for authorization. In unusual situations, the specialist or PCP may contact WVFH s Utilization Management Department at Renal dialysis services If home dialysis services are necessary, an authorization from WVFH s Utilization Management Department is needed. Audiology and speech therapy WVFH members under the age of 21 are eligible to receive audiological services including hearing aids and ear molds. The member s primary care practitioner (PCP) must issue a referral for audiological services to a Network, licensed practitioner, licensed audiologist or an outpatient hospital clinic. Prior to dispensing aids and/or ear molds, the audiological practitioner must obtain authorization through the ordering practitioner from WVFH s Utilization Management Department. Reimbursement rates for hearing aids, ear molds, repair parts and any specialty items not covered on the Medicaid Fee Schedule should be negotiated at the time of authorization, prior to rendering services. 166 P age

168 4.1 SELF-REFERRAL Introduction West Virginia Family Health (WVFH) members may refer themselves for the types of care listed below. Dental WVFH members obtain most of their health care services either directly from or upon referral by their Primary Care Physician (PCP), except for services available on a self-referral basis. Dental services are included as a self-referral service. Therefore, a referral from a WVFH member s PCP is not necessary for the member to seek care from a network dental provider or specialist. Certain oral surgery procedures, such as removal of partial or total bony impacted wisdom teeth and procedures which involve cutting of the jaw, are covered by WVFH through Scion s panel of network oral surgery providers. Members requiring these services should be referred by their primary care dentist to a network oral surgeon. The primary care dentist may need to provide x-rays or other clinical information to facilitate the referral. Procedures performed in the oral surgeon s office do not require prior authorization. If it is determined that the oral surgery treatment can only safely be performed in a Short Procedure Unit (SPU) or Ambulatory Surgical Center (ASC) facility, the dental provider must contact Scion Dental for authorization prior to rendering treatment. Dental specialty referral WVFH members may not self-refer for specialty dental care. Any WVFH participating dentist may refer a member to another participating dentist for specialty care services that are covered by following these guidelines: The participating dental provider may refer a member to a participating specialist without a written referral. Please provide the member with written or verbal dental care recommendations. If a specialist is not available in a member s area, please contact the Scion Dental Continued on next page 167 P age

169 4.1 SELF-REFERRAL, Continued Dental specialty care providers It is recommended that a general dentist evaluate a member before scheduling an appointment with a specialty dental care provider. However, if time does not permit a general dental evaluation, such as in the case of an emergency, the member may seek and receive treatment by a dentist specialist. In the case of an emergency, dental specialty care providers may provide services necessary to treat and stabilize the member s condition without a referral from a general dentist. Please contact the Scion Dental at for a listing of participating specialty dental care providers. Emergency Members are informed through the Member Handbook how and when to utilize emergency services. Eye examinations WVFH members who have covered vision benefits may self-refer to any Davis Vision Network provider for a routine eye exam. Corrective lenses and frames may be obtained through any Davis Vision Network optician, optometrist, or ophthalmologist. There is no need for the PCP to issue a referral. Should the member require additional medical services, rendered by a Davis Vision Network ophthalmologist or optometrist, the member will require a referral from the PCP. Behavioral health/ substance abuse Members are permitted to self-refer for behavioral health and substance abuse services. Please refer to the Quick Reference section of this manual for the telephone numbers for members to call. OB/GYN or family planning services Female WVFH members may self-refer to any Network OB/GYN for any condition, not just for an annual exam or suspected pregnancy. When a member self-refers to the OB/GYN s office, the OB/GYN s office is required to contact WVFH to verify eligibility of the member. WVFH members may also self-refer for family planning services. 168 P age

170 CHAPTER 4: HEALTH CARE MANAGEMENT UNIT 2: AUTHORIZATIONS IN THIS UNIT TOPIC SEE PAGE General Information 170 Criteria Used for Assessing Medical Appropriateness 170 Review/Determination of Medical Necessity 170 Utilization Management Contact Information 171 Services Requiring Authorization 172 Requesting an Authorization 173 Information Needed When Requesting an Authorization 173 Decision Time Frame 173 Expedited Authorization Requests 174 Medical Necessity Criteria 174 Post-Service Requests 175 Chiropractic Services 176 Durable Medical Equipment 177 Skilled Nursing Facility 179 Physical/Occupational/Speech Therapy 180 Rehabilitation Services 181 Extended Care in a Non-Hospital Facility 181 Cardiac and Pulmonary Rehabilitation Services 181 Home Health Care 182 Hospice Services 183 Pharmacy Services 184 New Technology P age

171 4.2 GENERAL INFORMATION Introduction Referrals and Authorizations are necessary in order to preserve the PCP s gatekeeper relationship with the patient. Both processes allow West Virginia Family Health (WVFH) to manage the care of its member population. The major differences between referrals and authorizations are highlighted below: Referrals allow the PCP to approve specialty services for members on their panel. Authorizations allow WVFH to confirm eligibility of the member prior to receiving services; to assess the medical necessity and appropriateness of care; to establish the appropriate site for care; and to identify those members who would benefit from case management. Authorizations will be discussed in this unit. For referral information, please see this manual s Chapter 4, Unit 1: Referrals. Criteria used for assessing medical appropriateness West Virginia Family Health s (WVFH s) Utilization Management Department assesses the medical appropriateness of services using McKesson s Interqual Procedure Criteria and the Department of Health and Human Resources, Bureau for Medical Services (BMS) definition of medical necessity when authorizing the delivery of health care services to plan members. Review/ Determination of medical necessity The definition of medical necessity is a determination that items or services furnished or to be furnished to a patient are reasonable and necessary for the diagnosis or treatment of illness or injury, to improve the functioning of a malformed body member, for the prevention of illness, or to achieve ageappropriate growth and development. Determination of Medical Necessity for covered care and services, whether made on a Prior Authorization, Concurrent Review, Retrospective Review, or exception basis, must be documented in writing. The determination is based on medical information provided by the Member, the Member s family/caretaker and the PCP, as well as any other providers, programs, or agencies that have evaluated the Member. All such determinations must be made by qualified and trained health care providers. A health care provider who makes such determinations of Medical Necessity is not considered to be providing a health care service under this Provider Manual. WVFH may not make specific payments, directly or indirectly, to a physician or physician group as an inducement to reduce or limit medically necessary services furnished to any particular Member. Indirect payments may include offerings of Continued on next page 170 P age

172 4.2 GENERAL INFORMATION, Continued Review/ determination of medical necessity (continued) monetary value (i.e., stock options or waivers of debt) measured in the present or future. WVFH requires that all reviewers make utilization management decisions based only on the medical necessity and appropriateness of care and the availability of coverage under our benefit contracts. We do not reward anyone conducting utilization review for issuing denials of coverage. We do not use financial incentives to encourage denials or other decisions that could result in underutilization of needed services or otherwise compromise members health. Decision time frame WVFH must make authorization decisions and provide notice as expeditiously as required by the enrollee s health condition and no later than seven (7) calendar days of receiving the request for service for the purposes of standard authorization decisions. This seven (7) calendar day period may be extended up to seven (7) additional calendar days upon request of the enrollee or provider, or if WVFH justifies to the Bureau of Medical Services (BMS) in advance and in writing that the enrollee will benefit from such extension. Utilization Management contact information The Utilization Management Department is committed to assuring prompt, efficient delivery of healthcare services and to monitor quality of care provided to WVFH members. The Utilization Management Department can be contacted at between the hours of 8:30 AM and 4:30 PM, Monday through Friday. The following options can be used to reach WVFH s Utilization Management Department for specific information: REASON FOR CALL OPTION Calls for DME, Therapy, or Chiropractic Services Option 3 Calls for Emergency Inpatient Admissions, Concurrent Review, Home Health Updates, or IV Infusion Option 4 When calling before or after operating hours or on holidays, practitioners are asked to leave a voic message and a Utilization Management Representative will return the call the next business day. Urgent requests and home health requests requiring a visit when the WVFH Utilization Management Department is closed, or urgent/emergency inpatient place of service admission called in after hours are directed to call A WVFH Medical Director is available for review of these requests when necessary. For urgent or emergency situations, WVFH requires that the practitioner notify the plan within forty-eight (48) hours or two (2) business days of rendering the service. 171 P age

173 4.2 SERVICES REQUIRING AUTHORIZATION List of services requiring authorization The following services require an authorization from WVFH: All Hospital Admissions Select Outpatient Surgical Procedures: Bariatric Surgery/Stapling Removal of Breast Implant Breast Reduction Rhinoplasty Carpal Tunnel Surgery Spinal Neuro Stimulator Services Corneal Transplants Hysterectomy TMJ Surgery Panniculectomy Varicose Vein Tubal Ligations Private Duty Nursing Orthoptics/Visual Training Abortions Sterilizations Transplants/Implants Genital Reconstruction Blepharoplasty Speech, Occupational, or Physical Therapies (Members can be referred to any WVFH Network hospital for speech, occupational, or physical therapy sessions) Outpatient Cardiac Rehabilitation and Pulmonary Rehabilitation (Members can be referred to any WVFH Network provider for rehabilitation sessions) Referrals for specialty care requiring greater than three visits, unless otherwise noted All services to be provided by an out-of-network practitioner/provider (including durable medical equipment and home health) Durable Medical Equipment items $500 or greater or not covered on the Medicaid Fee Schedule regardless of cost All Durable Medical Equipment rentals $500 or greater monthly Genetic Testing Home Health Care All non-covered services Hospice Hearing aids, ear molds, dispensing fees, as well as hearing aid repair services Skilled Nursing Facility Admissions Rehabilitation Hospital Admissions Chiropractic Services All visits, including the initial visit Dental Services (see page 52 in Scion Dental Provider Manual available on the WVFH website at P age

174 4.2 REQUESTING AN AUTHORIZATION Overview Authorization is the responsibility of the admitting practitioner or ordering provider and can be obtained by calling WVFH s Utilization Management Department at If a service requires authorization and is being requested by a Network specialist, the specialist s office must call WVFH to authorize the service. Hospitals may verify authorization by calling the WVFH Utilization Management Department. Physical, occupational, or speech therapy requires authorization by the ordering practitioner or the primary care practitioner (PCP). Information needed when requesting an authorization The following information is needed to authorize a service. Please have this information available before placing a call to the Utilization Management Department: 1. Member Name 2. Member s 8-digit WVFH ID Number 3. Diagnosis (ICD-10 Code or precise terminology) (or its replacement) 4. Procedure Code (CPT-4, HCPCS, or MA Coding) or billing codes for durable medical equipment requests 5. Treatment Plan 6. Date of Service 7. Name of Admitting/Treating Practitioner 8. Name of the Practitioner/Provider requesting the authorized treatment 9. Provider of Service 7-digit WVFH ID Number 10. History of the current illness and treatments 11. Any other pertinent clinical information When a call is received, the above information will be reviewed, and the member s eligibility verified. However, since a member s eligibility may change prior to the anticipated date of service, eligibility must be verified on the date of service. Decision Time frame WVFH must make authorization decisions and provide notice as expeditiously as required by the member s health condition, and no later than seven (7) calendar days of receiving the request for service for the purposes of standard authorization decisions. This seven (7) calendar day period may be extended up to seven (7) additional calendar days upon request of the enrollee or provider, or if WVFH justifies to BMS in writing that the member will benefit from such extension. Continued on next page 173 P age

175 4.2 REQUESTING AN AUTHORIZATION, Continued Expedited authorization requests WVFH must provide an expedited authorization for services when the provider indicates that the standard time frame could seriously jeopardize the member s life or health or ability to attain, maintain, or regain maximum function. WVFH must make the expedited authorization decision and provide notice to the member as expeditiously as the member s health condition requires, but no later than seventytwo (72) hours after receipt of the request for service authorization. This seventytwo (72) hour period may be extended up to fourteen (14) additional calendar days upon request of the enrollee or provider, or if WVFH justifies to BMS in writing that the member will benefit from such extension. WVFH must provide thirty (30) days notice to providers before implementing changes to policies and procedures affecting the service authorization process. However, in the case of suspected fraud, waste, or abuse by a single provider, WVFH may implement changes to policies and procedures affecting the service authorization process without the required notice period. Medical necessity criteria The definition of Medical Necessity is as follows: A service or benefit is medically necessary if it is compensable under the Medicaid Program and a determination that items or services furnished or to be furnished to a patient are reasonable and necessary for the diagnosis or treatment of illness or injury, to improve the functioning of a malformed body member, for the prevention of illness, or to achieve age-appropriate growth and development. Medical Necessity criteria are established guidelines to be applied by nonphysician, licensed professionals to authorize services as medically necessary and at the appropriate level of care. If an authorized service is not able to be approved as proposed by the practitioner, alternate programs such as home health care, rehabilitation, or additional outpatient services will be suggested to the practitioner by the UM staff. If an agreement cannot be reached between the practitioner and the Utilization Management staff, the case will be referred to WVFH s Medical Director for review. A practitioner may appeal the decision within ninety (90) days of the date of the denial notice. Please refer to this manual s Chapter 3, Unit 4: Member and Provider Disputes for the process to appeal a decision. The determination is based on medical information provided by the member, the member s family/caretaker and the primary care practitioner (PCP), as well as any other practitioner/providers, programs, agencies that have evaluated the member. All such determination must be made by qualified and trained practitioners/providers. Continued on next page 174 P age

176 4.2 REQUESTING AN AUTHORIZATION, Continued Post-service requests Any service rendered by a Network Provider without an authorization will be reviewed for medical necessity within 180 days from the date of service. Submit records and a cover letter requesting a retrospective review to: West Virginia Family Health Attention: Medical Review P.O. Box Pittsburgh, PA Retrospective reviews will be completed within 60 days of the request. The decision is final and binding. 175 P age

177 4.2 CHIROPRACTIC SERVICES Requesting authorization Any Network practitioner may request authorization for chiropractic services by calling WVFH s Utilization Management Department at All visits, including the initial visit, require authorization by WVFH and must be medically necessary. Member eligibility must be verified prior to rendering services by calling DIVA at Members may self-refer for chiropractic services; however, the chiropractic office must call WVFH for authorization including the initial evaluation. Services The only therapy WVFH will authorize is a simple manipulation for an acute spinal problem. Other requests will be referred to the Medical Director for review and determination. Additionally, one chiropractic evaluation will be authorized per course of treatment. Requests for children under the age of 16 are referred to WVFH s Medical Director for approval. Only one visit per day can be authorized. Radiological services Network chiropractors may render radiological services in the office. WVFH only reimburses chiropractors for the professional and technical components of covered diagnostic radiology services (CPT ) if the chiropractor performs both parts of the procedure. Only one interpretation of an x-ray will be reimbursed. X- rays must be taken on certified radiology equipment that complies with all State and Federal requirements. Members requiring radiological services beyond the services listed above, such as a CT scan or MRI should be referred back to PCP. 176 P age

178 4.2 DURABLE MEDICAL EQUIPMENT Introduction WVFH members are eligible to receive any covered and medically necessary durable medical equipment (DME) needed for home health care. Guidelines When ordering DME, these procedures must be followed: If the cost of a single item or multiple quantities of a single item is $500or greater as reimbursed by Medical Assistance, the ordering practitioner/provider must obtain authorization from the Utilization Management Department. A referral from the PCP is not required, but a written prescription and WVFH authorization are necessary to obtain the item. Rental equipment must be authorized if the monthly rental cost is $500 or greater. Covered items under $500 can be obtained from a Network durable medical equipment provider with a prescription from the ordering practitioner/provider. A referral from the PCP and WVFH authorization is not required. Provider Services or Utilization Management can direct practitioners to a contracted vendor to supply durable medical equipment. DME vendors are also listed in the WVFH On-Line Provider Directory at A written prescription is required to obtain the item. Any item not covered by Medicaid, regardless of price, requires authorization by the Utilization Management Department. Regardless of price, when a miscellaneous code is requested, an authorization from WVFH s Utilization Management Department is required. Due to frequent interruptions of Medicaid coverage, WVFH strongly recommends that all providers verify eligibility if the need for an item or service extends beyond the calendar month in which the authorization was given. All medical supplies including wound care, ostomy, enteral products, diapers, and incontinence products must be obtained through a contracted DME vendor as opposed to a Network pharmacy. Oral enterals must be obtained through a Network DME provider. Based on the cost of the product ordered, an authorization from WVFH s Utilization Management Department may be necessary if the product is $500 or greater. Please do not direct members to retail pharmacies such as Rite Aid, etc. for these services. Continued on next page 177 P age

179 4.2 DURABLE MEDICAL EQUIPMENT, Continued Guidelines (continued) When ordering DME, practitioners can contact a Network DME provider to receive the appropriate billing code(s) before calling WVFH s Utilization Management Department. Or practitioners can call and request WVFH s staff work directly with a Network DME provider to obtain the appropriate billing code and cost. If you need an updated list of Network providers, please call WVFH s Provider Services Department at , or access the On-Line Provider Directory at DME provided by non-network providers requires an authorization from the WVFH Utilization Management Department. Incontinence items will be covered by WVFH without requesting an EOB from any other plan; however, if the billed charge is $500 or greater, and/or a miscellaneous code is used to request the supply, a Utilization Management authorization will be required according to plan guidelines. Any services provided by non-network providers always require an authorization. Information needed when ordering DME The following information will provide assistance to offices when ordering DME services: 1. Patient Name, WVFH ID Number, Prior Authorization Number (If Applicable) 2. DME Vendor/Provider Number 3. Ordering Practitioner/Provider 4. Diagnosis 5. Name of Requested Equipment, Medicaid Fee Schedule Code, Cost 6. Is this a Purchase or a Rental Request? 7. Amount of Items Requested Over What Period of Time (if requesting rental) 8. Clinical Information to Support the Request To obtain approval for durable medical equipment, please call WVFH s Utilization Management Department at P age

180 4.2 SKILLED NURSING FACILITY Skilled nursing facility admissions Should a member be in need of admission to a nursing facility, the primary care practitioner (PCP), attending practitioner, hospital Utilization Review Department, or the nursing facility should contact the WVFH Utilization Management Department at WVFH will coordinate the necessary arrangements between the PCP and the nursing facility to provide the member with continuity and coordination of care. 179 P age

181 4.2 PHYSICAL/OCCUPATIONAL/SPEECH THERAPY Policy All physical therapy, occupational therapy, and speech therapy require an authorization from WVFH s Utilization Management Department. The ordering provider of the therapy must contact WVFH s Durable Medical Equipment/Therapy Team to obtain the initial authorization. When a physical, occupational, or speech therapy provider has a request for continuation of therapy services, WVFH will accept a faxed copy of the prescription signed by the ordering Network practitioner in lieu of a telephone call from the Network practitioner. Authorization process The following process must be observed: 1. The therapy provider must first call WVFH to request continuation of therapy services before faxing the prescription (blind faxes will not be accepted.) During this telephone call, the therapy provider will receive information identifying which staff member s attention the fax should be sent to. 2. The therapy provider will fax to WVFH the signed prescription and the current progress notes, plan of treatment, and goals, which support the medical necessity of the therapy services. 3. The therapy provider will be called back when the request for therapy services is approved. 4. When the request results in a denial, the current appeal process remains unchanged. When the therapy provider does not have a signed prescription, the ordering practitioner must notify WVFH of the request for continued services. 180 P age

182 4.2 REHABILITATION SERVICES Extended care in a non-hospital facility Should a member require extended care in a non-hospital facility for rehabilitation purposes, the PCP, attending practitioner, hospital, or rehabilitation facility should call the WVFH Utilization Management Department at The Utilization Management Department will provide assistance in appropriate placement thus ensuring continuity and coordination of care. Cardiac and pulmonary rehabilitation services All cardiac and pulmonary rehabilitation services require an authorization from WVFH s Utilization Management Department. The ordering provider of the treatment must contact WVFH s Utilization Management Department at , to obtain the initial authorization. 181 P age

183 4.2 HOME HEALTH CARE Overview WVFH encourages the use of home-based services as an alternative to hospitalization when medically appropriate in order to: Allow for timely and appropriate discharge from the hospital. Avoid unnecessary admissions of members who could effectively be treated at home. Permit members to receive care in greater comfort due to familiar surroundings. Home-based services Home-based services may include, but are not limited to the following type of services: Skilled Nursing Speech Therapy Hospice Home Health Aid Physical Therapy IV Therapy Infant Care Occupational Therapy High-Risk Pregnancy Social Services Authorization required for all home-based services Authorization is required for all home-based services. The ordering practitioner is responsible for obtaining authorization. Please do not call the home health care provider directly. Due to frequent interruptions of Medicaid coverage, WVFH strongly recommends verification of eligibility if the need for an item or service extends beyond to the calendar month in which the authorization was given. Private duty nursing services WVFH s Case Management Department coordinates medically necessary private duty nursing services with the ordering practitioner and the home health care provider. The Case Management Department can be reached at Non-private duty home health care needs WVFH s Utilization Management Department coordinates medically necessary non-private duty home health care needs with the ordering practitioner and the home healthcare provider. Please call WVFH s Utilization Management Department at Billing WVFH cannot accept bills in half-hour increments. Providers must bill in whole hours. 182 P age

184 4.2 HOSPICE SERVICES WVFH coordinates hospice services Should a member be in need of hospice care, the PCP, attending physician, hospital Utilization Review Department, or hospice agency should contact WVFH s Utilization Management Department at WVFH will coordinate the necessary arrangements between the PCP and the hospice provider in order to assure continuity and coordination of care. Due to frequent interruptions of Medicaid coverage, WVFH strongly recommends verification of eligibility if the need for an item or service extends beyond the calendar month in which the authorization was given. 183 P age

185 4.2 PHARMACY SERVICES Fee for service pharmacy program As of July 1, 2017, pharmacy services for West Virginia Family Health members will be administered by West Virginia Medicaid s Traditional Fee for Service Pharmacy Program. 184 P age

186 4.2 NEW TECHNOLOGY Requires Medical Director review/ authorization Any new technology identified during the Utilization Management review process, and requiring authorization for implementation of the new technology, will be forwarded to the Medical Director for authorization. If there is a question about the appropriate governmental agency approval of the technology, the Medical Director will investigate the status of the technology with the agency, consult appropriate specialists related to the new technology, and/or utilize the contracted services of Hayes, Inc. for information related to the new technology. If the technology has not been approved by appropriate governmental regulatory bodies, the Medical Director will discuss the need for the specifically requested technology with the primary care practitioner (PCP) and will consult with a Network specialist from the WVFH expert panel regarding the use of the new technology. If it is determined that no other approved technology is available and/or the Medical Director and consultants feel that the possibility for a positive outcome would be achieved with the use of the new technology, approval may be given with the stipulation that the provider obtain the necessary signatures from the member needed for any investigational treatment/procedures. 185 P age

187 CHAPTER 4: HEALTH CARE MANAGEMENT UNIT 3: CASE MANAGEMENT IN THIS UNIT TOPIC SEE PAGE Gateway to Lifestyle Management Programs Overview 187 Maternity Program 188 Asthma Program 189 Diabetes Program 190 Cardiac Program 191 Chronic Obstructive Pulmonary Disease (COPD) 192 Program Special Needs Case Management 193 Complex Case Management P age

188 4.3 LIFESTYLE MANAGEMENT PROGRAMS OVERVIEW Gateway to Lifestyle Management programs West Virginia Family Health (WVFH) wants members to live happy, healthy lives. Lifestyle management programs are offered to help WVFH members stay well and also manage any conditions they may have. WVFH also provides Wellness Coaches to assist members in making lifestyle changes to maintain or improve their health. Wellness Coaches Dietician Certified Diabetic Educator CDE) Rehab Coach Gateway to Lifestyle Management programs offered to WVFH members include the following: Maternity Program Asthma Program Diabetes Program Cardiac Program Chronic Obstructive Pulmonary Disease (COPD) Program For program details, please see the applicable sections of this unit. 187 P age

189 4.3 MATERNITY PROGRAM Program overview The Maternity Program offers maternity care coordination to improve the frequency of prenatal and postpartum care to reduce the incidence of low birth weight, pre-term deliveries and NICU admissions. This is a population-based program directed toward improving outcomes for all pregnant members. Specific interventions are designed to identify and prospectively intervene with members at high risk for adverse pregnancy outcomes. All identified pregnant WVFH members are automatically enrolled once we identify them with one of the high risk maternity conditions via the West Virginia Prenatal Risk Screening Instrument (PRSI). Maternity Case Managers telephonically contact these members. Members are able to opt-out if they choose. Membership in the Maternity Program is voluntary. If at any time your patients wish to stop participating in the program, they only need to call. Member benefits and support The program will provide the following member benefits and support: Patient education Prenatal educational packet mailed to all identified pregnant members Assistance with coordinating home care, DME, and transportation needs Information on smoking cessation with referral to the state Quitline Member newsletter with related maternity articles Online member portal gives patients 24/7 access to personal benefit information, medical claims, physician and provider searches, and health and wellness resources. Maternity Program information is available via Maternity Reward Program Provider benefits and support Provider benefits and support include: Support from our case managers and other health care staff to ensure that your patients understand how to best manage their pregnancy and selfevaluate their health status. Health education information mailed to all identified pregnant members. Telephonic case management and coordination of care for high risk patients. A bonus payment to PCPs and OB/GYNs for rendering initial prenatal visit within the first trimester. Provider website with access to clinical guidelines, reference materials, and other helpful information. FOR MORE INFORMATION For more information or to refer a patient to the Maternity Program, please call P age

190 4.3 ASTHMA PROGRAM Program overview The WVFH Gateway to Lifestyle Management Asthma Program emphasizes patient education, self-management, practitioner education and support to increase appropriate medication use and reduce acute care asthma utilization. WVFH members 2 years of age and older are eligible for the program. Members are automatically enrolled once they are identified with asthma, but they are able to opt out if they choose. Case Managers are available by phone. Member benefits and support The program will provide the following member benefits and support: Case managers are available to help support your plan of care by providing telephonic management. This can help your patients understand the importance of medication adherence and asthma control Your patients will receive asthma educational materials and selfmanagement tools Information on smoking cessation with referral to the state Quitline Member newsletter with asthma related articles Online member portal gives patients 24/7 access to personal benefit information, medical claims, physician and provider searches, and health and wellness resources. Asthma Program information is available via Provider benefits and support Provider benefits and support include: Support from our case managers and other health care staff to ensure that your patients understand how to best manage their condition and selfevaluate their health status. Patient education and assistance with co-existing conditions, smoking cessation and medication compliance supports optimal self-management. Provider website with access to clinical guidelines, reference materials, and other helpful information. Membership in the Asthma Program is voluntary. If at any time your patients wish to stop participating in the program, they only need to call. FOR MORE INFORMATION For more information or to refer a patient to the Asthma Program, please call P age

191 4.3 DIABETES PROGRAM Program overview The WVFH Gateway to Lifestyle Management Diabetes Program emphasizes education and personal responsibility for diabetes management to reduce the need for hospitalizations, ER visits and to prevent diabetic complications. Case Managers are available by phone for members and physicians. All adult and pediatric WVFH members with Type 1 or Type 2 diabetes are eligible for this program. Members are automatically enrolled once we identify them with diabetes. They are able to opt-out if they choose. Member benefits and support The program will provide members with the following benefits and support: Patient education regarding co-existing conditions, smoking cessation medication compliance and blood glucose monitoring Diabetic members identified as high-risk receive telephonic case management by a case manager or wellness coach Reinforcement of your plan of care Text message program to help members learn about diabetes and form healthy habits Targeted telephonic and/or mailed reminders to patients who are due for diabetes-related labs/tests Member newsletter with diabetes related articles Diabetes educational materials Online member portal gives patients 24/7 access to personal benefit information, medical claims, physician and provider searches, and health and wellness resources. Diabetic information on Provider benefits and support Provider benefits and support include: Support from our case managers and wellness coaches to ensure that your patients understand how to best manage their condition and evaluate their health status. Diabetic educational reminder materials are mailed to your patients Provider website with access to clinical guidelines, reference materials, and other helpful information. Patient education with co-existing conditions, smoking cessation and glucometer use reduces likelihood of hospital admissions FOR MORE INFORMATION For more information or to refer a patient to the Diabetes Program, please call P age

192 4.3 CARDIAC PROGRAM Program overview The WVFH Gateway to Lifestyle Management Cardiac Program provides patient education and self-empowerment for medication adherence to reduce the need for hospitalizations and ER visits and to delay the onset of cardiac complications. WVFH members, age 21 or older, with a diagnosis of congestive heart failure (CHF), myocardial infarction (Ml), and coronary artery disease (CAD) are eligible for the program. Members are automatically enrolled once we identify them with one of these cardiac conditions. Membership in the Cardiac Program is voluntary. If at any time your patients wish to stop participating in the program, they only need to call. Member benefits and support The program will provide the following member benefits and support: Patient education and self-management tools Cardiac information High-risk cardiac patients with inpatient admissions may receive telephonic case management by a case manager or wellness coach Information on smoking with referral to the state Quitline Member newsletter with cardiac related articles Online member portal gives patients 24/7 access to personal benefit information, medical claims, physician and provider searches, and health and wellness resources. Cardiac Program information is available via Home care and DME needs are coordinated through the WVFH Case Manager Provider benefits and support Provider benefits and supports include: Support from our case managers and other health care staff to ensure that your patients understand how to best manage their condition and evaluate their health status Cardiac specific educational materials are mailed to patients Patient education for co-existing conditions, smoking cessation, medication compliance, and weight supports optimal self-management Provider website with access to clinical guidelines, reference materials, and other helpful information. FOR MORE INFORMATION For more information or to refer a patient to the Cardiac Program, please call P age

193 4.3 CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) PROGRAM Program overview The WVFH Gateway to Lifestyle Management COPD Program emphasizes patient education, self-management, and medication adherence. The program promotes lifestyle modifications and safety to reduce inpatient utilization, emergency room visits and preventable flare ups. WVFH members 21 years of age and older with a diagnosis of COPD are eligible for this program. Members are automatically enrolled once they are identified with COPD, but membership in the COPD Program is voluntary. If at any time your patients wish to stop participating in the program, they only need to call. Member benefits and support The Program will provide the following member benefits and support: Case managers are available to support your plan of care. They can provide telephonic management to help educate your patients about their COPD. Your patients will receive COPD educational materials and selfmanagement tools. Information on smoking cessation with referral to the state Quitline. Member newsletter with COPD related articles. Online member portal gives patients 24/7 access to personal benefit information, medical claims, physician and provider searches, and health and wellness resources. COPD program information is available via Provider benefits and support Provider benefits and support include: Support from case managers and other health care staff to ensure that your patients understand how to best manage their condition and evaluate their health status Motivate your patients to assume a proactive role in their health Provider patient education about comorbid conditions to help reduce hospitalizations Provide website with access to clinical guidelines, reference materials, and other helpful information FOR MORE INFORMATION For more information or to refer a patient to the COPD Program, please call P age

194 4.3 SPECIAL NEEDS CASE MANAGEMENT Goal of SNCMU The goal of the Special Needs Case Management Unit (SNCMU) is to intervene in medically or socially complex cases that may benefit from increased coordination of services to optimize health and prevent disease. Contact information A Special Needs Case Manager is available at , Monday through Friday from 8:30 AM to 4:30 PM, to assist with coordination of the member s health care needs. When calling after hours or on holidays, Member Services is available at SNCMU responsibilities The responsibilities of the SNCMU include: Liaison with various health care practitioners, community social service agencies, advocacy groups and other agencies that the Medical Assistance population may interface with; Case management of children with medically complex special needs; Coordination of services between primary care, specialty, ancillary, and behavioral health practitioners within and outside the network; Facilitation of dispute resolution including informing members of the complaint, grievance, and appeal mechanism that is available to the member; and Facilitation of members access to city, county, and Commonwealth social agencies for those members with complicated ongoing social service needs that affect their ability to access and use medical services. Criteria for referral The following problems and/or diagnoses are examples of appropriate referrals to the Special Needs Case Management Team: Children with special health care needs (i.e., Cerebral Palsy) HIV/AIDS Mental Health or Substance Abuse Issues Mental Retardation/Developmental Disabilities WVFH allows for a standing referral to a specialist for sixty (60) days or to serve as a primary care practitioner (PCP) in certain pre-authorized situations. The specialist must be an existing WVFH practitioner, must be agreeable to following WVFH s requirements for acting as a PCP, and must receive prior authorization by WVFH s Medical Director. Practitioners interested in obtaining more information regarding this process should contact Provider Servicing at P age

195 4.3 COMPLEX CASE MANAGEMENT Program overview WVFH provides a Complex Case Management Program for eligible members. Participation in this program is voluntary. A Case Manager can help your patient to better understand their health conditions and benefits and can also help to coordinate health care services by interacting with providers. A Case Manager can tell your patient about community organizations and resources that may meet their needs. Member eligibility Eligible members may include: Members with multiple medical conditions Members with a complex medical history Members that need assistance to become more self-reliant in managing their health care Referrals To make a referral, please call: , WVFH will review the request for enrollment and make the final decision for inclusion in the program. 194 P age

196