Provider Workshops March 2012

Transcription

1 Provider Workshops March 2012

2 Agenda Welcome and Introductions BMS Policy & Program Updates National Correct Coding Initiative (NCCI) Medicaid Programs Health Homes Take Me Home WV (Money Follows the Person) Traumatic Brain Injury (TBI) Waiver Program Program Integrity Provider Enrollment & Screening Risk Levels & Site Visits Provider Re-Enrollment Web-Based Provider Enrollment Application Provider Application Demonstration 2

3 Agenda (continued) 5010 Electronic Transactions & Updates One NPI to Multiple WV Medicaid Provider IDs (One to Many) WV Health Information Network (WVHIN) Health Information Exchange and WVDirect Health Information Technology (HIT) APS Healthcare Eligibility Verification of Prior Authorization (PA) Requests Out-Of-Network Requests Denials and Reconsiderations Provider Registration with APS Healthcare Provider Automated Capabilities Automated Voice Response System Web Portal Electronic Transactions WV Medicaid Training Center 3

4 General Policy Updates Updates to BMS Provider Manual Chapters > Proposed changes posted on BMS website > 30 Day Public Comment Period > Recent updates to Chapters for Partial Hospitalization Program, PRTF, Pharmacy, Hospice, Nursing Facility Devices pacemakers, implantable defibrillators, nerve stimulators > Policies for coverage; some devices require PA OT, PT, Speech Therapy > If employed by hospital or CAH, facility may bill for therapist s services; pay-to must be facility 4

5 General Policy Updates (continued) Transperineal Stereotactic Template-Guided Saturation Prostate Biopsy > CPT code > Coverage limited to specific diagnoses > Requires Prior Authorization CTs, MRIs or PET Scans in Office Setting > Effective 1/1/2012, CMS requires accreditation by American College of Radiology, Intersocietal Accreditation Commission or Joint Commission Radiologic Guidance for Needle Placement by Different Modalities > Effective 03/01/12, WV Medicaid will allow one unit of service per day for CPT codes 76942, 77002, 77003, and regardless of the number of needle placements performed. 5

6 General Policy Updates continued Fluoride Varnish coverage for children at high risk of dental caries > Effective 01/16/12, for children age 6 months to 36 months > Primary care providers (physicians, APRNs, physician assistants) > Limited to 4 applications per year 2 applications by dentist and 2 by medical professional > Must complete training through WVU School of Dentistry Information about course at Reminder: HRSA s 340 B Program Participants > For WV Medicaid members provided drugs from 340B inventory, billing must be based on 340B-acquisition cost Reminder: Documentation Retention > Required by WV Medicaid policy (Chapter 320) to retain all documentation supporting medical necessity for a period of not less than 5 years from date of service 6

7 Coding Updates National Correct Coding Initiative (NCCI) > Mandated by the Affordable Care Act of 2010 to incorporate NCCI into Medicaid claims processing > All Medicaid NCCI edits with Molina system upgrade > Applies to CMS 1500 and outpatient hospital claims > Testing continues > Changes in claims processing Column 1, Column 2 Code Pairs Medically Unlikely Edits > For more information, go to CHIP-Program-Information/By-Topics/Data-and-Systems/Medicaid- Nation-Correct-Coding-Initiative.html 7

8 Coding Updates ICD 10 > Implementation delayed per Centers for Medicare and Medicaid Services Modifiers > Assistant-at-Surgery Must be billed with appropriate modifier (-80,-81,-82,-AS ) Operative report must reflect services provided by assistant atsurgery > Transportation Must use modifiers to indicate origin and destination Documentation must support codes billed > Functional or Bypass Examples: Modifier -25 or -59 Documentation must support codes billed 8

9 Medicaid Programs Health Homes Health Homes for Members with Chronic Condition > Program is intended to improve the health of Medicaid members who may need a variety of services to address primary and acute care, behavioral health care, and long-term care services. > BMS has been working with stakeholders across the state > WV Health Improvement Institute to develop State Plan Amendment (SPA) > SPA has been reviewed by Substance Abuse and Mental Health Services Administration (SAMHSA) as required by CMS > Draft SPA at 001%20WV%20draft%20HH%20SPA%20Template% pdf > Next stakeholder call April 12, 2012 Register at WV Health Improvement Institute s website 9

10 10 Medicaid Programs Health Homes (cont d) To be eligible, Medicaid member must have 2 conditions among those listed below: > Diabetes > Cardiovascular disease > Asthma/COPD > Alzheimer s Disease > Serious Mental Illness > Schizophrenia spectrum disorder > Bipolar disorder > Major depression > Anxiety > Attention Deficit Hyperactive Disorder > Pervasive Developmental Disorder > Substance abuse OR one condition listed above and one of the following risk factors: > BMI > 25 > Tobacco use > High utilization of ED & hospitalization > Living in foster care > Residence in a long term care facility

11 Medicaid Programs Health Homes (continued) Provider Infrastructure > Designated primary care physician or advanced practice nurse providers working with multidisciplinary teams in a variety of possible settings primary care and solo medical practices comprehensive community behavioral health centers with a primary care service base providers who serve special populations academic medical centers other entities meeting established qualifications Health Homes Team works together to Integrate Medical and Mental Health 11

12 Medicaid Programs Health Homes (continued) Six defined health home services > Comprehensive Care Management > Care Coordination > Health Promotion > Comprehensive Transitional Care > Individual and Family Support Services > Referral to Community and Social Support Services Health Information Technology Standards for Monitoring and Evaluation 12

13 Medicaid Programs Take Me Home WV Money Follows the Person Rebalancing Demonstration Project Federal grant to enhance services and supports for Medicaid members who wish to receive services in a home-based or community setting Will transition at least 600 individuals from institutional to community living over 5 year grant period Builds on successful Transition Navigator Pilot Program initiated by WV Olmstead Office Opportunity for improvement of home and communitybased services through quality monitoring via consumer and stakeholder participation 13

14 Medicaid Programs - TBI Waiver Program 14 Traumatic Brain Injury (TBI) Waiver Program > Started February 1, 2012 Available to assist individuals to return home following a TBI, rather than receiving nursing home care Covered services include: > Case Management > Personal Attendant Services (direct care support and transportation) > Cognitive Rehabilitation Therapy (CRT) > Participant-Directed Goods and Services Chapter 512 in BMS Provider Manual APS Healthcare serves as the Administrative Services Organization

15 TBI Waiver Program (continued) In order to be determined eligible for the TBI Waiver program, applicants must: > Be 22 years of age or older > Be a permanent resident of West Virginia > Have a TBI caused by an external force resulting in total or partial functional disability and/or psychosocial impairment > TBI cannot be degenerative or congenital in nature > Be approved as medically eligible for nursing home level of care > Score at a Level VII or below on the Rancho Los Amigos Levels of Cognitive Functioning Scale > Be inpatient in a licensed nursing facility, inpatient hospital or licensed rehabilitation facility to treat TBI at the time of application > Meet Medicaid Waiver financial eligibility requirements, as determined by DHHR or SSA, if they currently receive SSI > Choose to participate in the TBI Waiver Program as an alternative to nursing home care 15

16 Program Integrity CMS visit in May 2012 Recovery Audit Contractor (RAC) > Mandated by Affordable Care Act > Contract to be awarded by late summer 2012 > All claims and provider types open to review > Review methodology Data abstraction Desk review of medical records On-site visits > RAC will communicate requests/findings to providers > Recovery by BMS > Appeal process via BMS > For more info: Reminder: Failure to submit medical records for Program Integrity review may result in payhold by BMS 16

17 Provider Enrollment & Screening Provider enrollment and screening requirements mandated by ACA > Additional guidance released December 23, 2011 > Guidance pending on Criminal Background Check and Fingerprinting BMS currently accepting paper enrollment application + supplemental pages > Updates to Supplemental Pages Required Practice Location Information All future enrollment will require copy of most recent Medicare approval letter BMS now has access to information in Medicare s Provider Enrollment System (PECOS) 17

18 Provider Enrollment & Screening (continued) Application fee of $ for CY 2012 > Required for institutional providers > Application fee waived if paid to Medicare or another State s Medicaid program or CHIP > Hardship Exception Request available Form letter and supportive documentation must be submitted with enrollment application Request for hardship exception is sent to CMS by Medicaid CMS makes decision and notifies Medicaid Enrollment application on hold until CMS decision received Ordering/referring providers > Required to enroll 18

19 Provider Enrollment & Screening (continued) Risk Levels > Apply to all providers > Based on risk of fraud, waste or abuse Database Checks > OIG s List of Excluded Individuals & Entities (LEIE) > GSA s Excluded Parties List System (EPLS) > National Practitioner Data Bank (NPDB) > SSA Death Match File (SSA DMF) > State Medicaid Exclusion Lists & centralized MCSIS > State Licensing Boards Provider enrollment site visits to begin soon > Unannounced > Failure to allow site visit is basis for denial of enrollment or disenrollment 19

20 Provider Re-enrollment All WV Medicaid providers must be re-enrolled by Phased-in approach by provider type/risk level. Schedule will be placed on the web portal and banner pages. Providers will receive general notice 60 days prior to reenrollment start date. Then 30 days prior to re-enrollment start date, providers will receive letter that includes re-enrollment access code. Provider will have 30 days to complete re-enrollment or BMS may place provider on pay hold. Re-enrollment for specific provider types will be limited to paper. 20

21 21 Web-Based Provider Enrollment Application (PEA) Available in 2012 Dependent on Molina system upgrades Will accommodate newly enrolling and re-enrolling providers Need provider volunteers for testing phase Process for web-based re-enrollment > Phased-in approach by provider type/risk level > Schedule will be placed on the web portal and banner pages > Providers will receive general notice 60 days prior to re-enrollment start date > Then 30 days prior to re-enrollment start date, providers will receive letter that includes re-enrollment access code > Provider will have 30 days to complete re-enrollment or BMS may place provider on pay hold Process for newly enrolling providers > Must contact Molina for information and access code level, if applicable

22 Online Application Demo 22

23 5010 and D.0 Electronic Transactions CMS s regulatory requirements to convert from HIPAA (ASC) X12 version 4010A1 to ASC X12 version 5010 effective 1/1/2012. The Centers for Medicare & Medicaid Services (CMS) extended the HIPAA 5010 deadline for compliance enforcement will begin June 30, The new HIPAA 5010 electronic transaction standard will drive billing, reimbursement, and many administrative functions, as well as accommodate the larger ICD-10 code sets. 23

24 5010 and D.0 Electronic Transactions (cont d.) Molina became 5010 (Medical & Dental), and D.0 (Pharmacy) capable, and began accepting 5010 electronic transactions on 12/27/2011. > 837 I/P/D Claims Submissions Inbound > 276 (Inbound)/277 (Outbound) Claim Status > 270 (Inbound)/271 (Outbound) Member Eligibility > 835 Paid Claims Outbound/Upload File DDE (Direct Data Entry) to the Web portal is not impacted. 24

25 5010 and D.0 Electronic Transactions (cont d) 72% of WV Medicaid electronic claims submitters have been production certified to submit claims in the 5010 format. > Electronic Submitters are required to pass testing requirements to become production certified to submit 5010 electronic transactions. 3 Successful test files of not less than 15 transactions per file. All transactions claims must pass! > WV Medicaid 5010 Companion Guides are available on Molina s website at: Molina will be refreshing its claims payment system to expedite claims processing and response times in support of 5010 & ICD10 Federal Requirements. 25

26 One NPI to Multiple WV Medicaid Provider IDs Referred to as One to many provider records > This means one NPI to multiple Medicaid provider ID numbers. Separate NPI number can be obtained by NPESS CMS expects BMS/Molina to use NPI numbers on all transactions. Benefits Eliminates the use of taxonomy. Reduces delay of claims processing. Facilitates electronic enrollment. 26

27 Automated Voice Response System (AVRS) Advantages to using AVRS: Automated response No long hold times Save Your Time! Can be used at your convenience: > Available 24 hrs per day 7 days per week Use AVRS for: Member Eligibility Payment Information Claim Status Access to AVRS: Providers Members Pharmacy 27

28 How To Use AVRS Voice response will prompt caller to press 1 to use NPI or 2 to use Medicaid Provider ID > Use Rendering NPI/ ID for claim status > Use Pay To NPI / ID for accounts payable It is important to choose the correct option to avoid being transferred or hold times. 28

29 Molina s Web Portal - Advantages of Having a Web Portal Account Eliminate paper claim forms Saves time and money Updates and Important Billing Information Bulletins and Forms Molina s contact information User Guides Access to submit all claims free of charge through DDE (Direct Data Entry) Capability to Upload Multiple Claim(s) in 1 file (837 Transactions) Receipt of Electronic Remit 835 transactions with ability to auto-post payments in provider systems (dependent on provider s system capabilities) Receipt of Electronic version of Paper Remittance Advices Access to submit Member Eligibility Requests free of charge Capability of uploading up to 99 members for eligibility verification in 1 file (270 Transactions) & receive electronic response in 1 file (271 Transactions) Access to Provider s Medicaid Training Center currently in development 29

30 Registering For Web Portal Account 1. Complete Trading Partner Agreement (TPA) with EDI Transaction form 2. TPA & EDI Transaction form is located on the Molina website, 3. Health PAS Online Registration After receipt of completed TPA forms, Molina s EDI staff will contact you by with a link to set up username and password through the Health PAS Online Registration. For assistance, contact EDI at , Option 4. 30

31 Molina Web Portal Welcome Page 31

32 Web Portal Training & Provider Field Representatives Beth Roach Carrie Blankenship

33 West Virginia Medicaid Training Center The Provider Medicaid Training Center is currently under revision and development. Registration is required to access WV Medicaid Training Center. Access Training Center through web portal. First time registration use default password as WV-Provider. Training Center can be used for trainings, webinars, and scheduled classes provided by Molina. 33

34 Molina Web Portal WV Provider Medicaid Training Center 34

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