ICHP : Department of Health Care Policy & Financing Updates

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ICHP : Department of Health Care Policy & Financing Updates ICD-10 is live Effective October 1, 2015, ICD-10 is now active and replacing ICD-9 diagnosis codes.

ICD-9 diagnosis and surgical procedure codes will be required on claims that contain DOS or dates of discharge (DOD) on or before September 30, 20

1 ICHP : Department of Health Care Policy & Financing Updates ICD-10 is live Effective October 1, 2015, ICD-10 is now active and replacing ICD-9 diagnosis codes. Providers should note the ICD-10 implementation is Date of Service (DOS) specific: 1. ICD-9 diagnosis and surgical procedure codes will be required on claims that contain DOS or dates of discharge (DOD) on or before September 30, ICD-10 diagnosis and surgical procedure codes are required on claims that contain DOS or DOD on or after October 1, Claims submitted with both ICD-9 and ICD-10 codes will reject. Providers will have to submit two (2) different claims based on the DOS or DOD. There are a few Denial/Error code descriptions relating to ICD-9 that will change due to the implementation of ICD-10 on October 1, Providers may refer to Appendix R for a list of all error descriptions. Be sure to verify the correct DOS or DOD to determine which code is in error. Additional information can be found in the Provider Billing Manuals as well as the ICD-10 section of the Provider Implementation website. Continuous Eligibility for Non-MAGI Children Continuous eligibility provides children up to 12 months of Medicaid or CHP+ coverage, regardless of changes in the family's circumstances, with some exceptions. In March 2014, the Department implemented this policy for children who qualified for MAGI Medicaid or CHP+. Following implementation last year, the Department sought and received additional guidance from the Centers for Medicare and Medicaid Services that the program is intended for all children, regardless of the Medicaid program for which they qualify. Beginning on October 18, 2015, the Department will extend continuous eligibility for up to 12 months to Medicaid children in the following Non-MAGI categories: children eligible for Supplemental Security Income mandatory, Pickle, Disabled Adult Child, children in a Buy-In program and children in Long Term Care programs. Continuous eligibility will also apply to children under the age of 19 who are no longer eligible for Foster Care. Accountable Care Collaborative Statewide Update As of July, 2015, more than 919,000 clients were enrolled in the ACC. ICHP Client Enrollment as of September 15, 2015: 108,332

2 P a ge Provider Revalidation & Enrollment Wave Schedule Beginning September 15, 2015, all Colorado providers who want to continue, or begin, providing services to Medicaid and CHP+ members after March 31, 2016, will be required to revalidate and enroll under new federal enrollment screening criteria. To meet these new requirements, as well as to ensure that you are enrolled in our new claims processing system, Colorado providers must revalidate using our new Online Provider Enrollment (OPE) tool. Although our new OPE tool will launch in September of 2015, we are asking that you complete your revalidation during your assigned revalidation and enrollment wave. Based on CMS provider type and risk designation, the revalidation process may include a criminal background check, fingerprinting, and unannounced site visits - including pre-enrollment site visits for some providers. Visit our provider resources page for information specific to your provider type and information specific to the HCBS service provided (if applicable). Providers who fail to revalidate and enroll by March 31, 2016 may have their claims suspended or denied. Wave 1: Begin 9/15/15 & End 10/15/15 Clear Creek Eagle Garfield Gilpin Grand Jackson Moffat Rio Blanco Routt Summit Wave 2: Begin 10/1/15 End 10/31/15 Archuleta Delta Dolores Gunnison Hinsdale La Plata Mesa Mineral Montezuma Montrose Ouray Pitkin San Juan San Miguel Wave 3: Begin 11/1/15 & End 11/30/15 Baca Bent Boulder Broomfield Cheyenne Crowley Elbert Kiowa Kit Carson Larimer Lincoln Logan Morgan Otero Phillips Prowers Sedgwick Washington Weld Yuma Wave 4: Begin 12/1/15 & End 12/31/15 Alamosa Conejos Costilla Chaffee Custer El Paso Fremont Huerfano Lake Las Animas Park Pueblo Rio Grande Saguache Teller Wave 5: Begin 1/1/16 & End 1/31/16 Denver Douglas Jefferson Wave 6: Begin 2/1/16 & End 2/29/16 Adams Arapahoe Wave 7: Begin 3/1/16 & End 3/31/16 Out-of-state Medicaid & CHP+ provider

3 P a ge 3

4 P a ge 4 Member Co-Payments and Provision of Services This FAQ reiterates the Department s rule on the provision of services when a Medicaid member is unable to provide a co-payment at the point of service. Can an ACC-enrolled primary care medical provider (PCMP) deny services to a Medicaid member because that member is unable to provide a co-payment at the point of service? No. Under the Department s rules, Medicaid providers may not deny services because a Medicaid member is unable to make a co-payment at the time of service, though the client remains liable for the copayment at a later date. The Department encourages Regional Care Collaborative Organizations and ACC-enrolled PCMPs to collaborate to develop strategies for working with members who have trouble making co-payments. Services to children, pregnant women, and members residing in institutional settings (e.g. mental health institutes, nursing facilities), as well as Behavioral Health Organization (BHO), family planning, and certain preventive services, are exempt from co-pays. Additional information on co-payments can be found in the Colorado Code of Regulations, at the following link: % (p. 38). The relevant sections are excerpted below CLIENT (co-payment) RESPONSIBILITY Clients shall be responsible for the following co-payments: A. Hospital outpatient, $3.00 per visit B. Physician (M.D. or D.O) office or home visit, $2.00 per visit C. Rural health clinic, $2.00 per visit. Page 2 of D. Brief, individual, group and partial care community mental health center visits except services which fall under Home and Community Based Service programs, $2.00 per visit E. Pharmacy, $1.00 per prescription or refill for generic or multi-source drugs and $3.00 per prescription for single-source or brand name drugs F. Optometrist, $2.00 per visit G. Podiatrist, $2.00 per visit H. Inpatient hospital, $10.00 per day up to 50% of the Medicaid rate for the first day of care in the hospital I. Psychiatric services, $.50 per unit of service. A unit is a 15 minute segment.

P a ge 5 8.754.1.J. Durable medical equipment/disposable supply services, $1.00 per date of service. 8.754.1.K. Laboratory services, $1.00 per date of service. 8.754.1.L. Radiology services, $1.

5 P a ge J. Durable medical equipment/disposable supply services, $1.00 per date of service K. Laboratory services, $1.00 per date of service L. Radiology services, $1.00 per date of service M. Emergency services, $0 co-pay. It is the provider s responsibility to identify emergency on the claim form so that the fiscal agent can exempt the service from co-payment NON-EMERGENCY SERVICES - Non-emergency services in the emergency room are considered to be outpatient hospital services and shall be subject to the same co-payment amount as a hospital outpatient visit EMERGENCY TREATMENT - Prescription drugs administered during emergency treatment shall be considered part of the treatment and are not subject to co-payment PRESCRIPTIONS - All prescriptions written in the emergency room or elsewhere are subject to the co-payment set forth in Paragraph E. above PROVIDERS A. The co-payment amount charged by a provider shall not vary depending on the cost of the specific service being rendered, except in the case of pharmacy services, where a copayment differential is established for generic or multi-source versus single-source or brandname drugs B. A provider may not deny services to an individual when such clients are unable to immediately pay the co-payment amount. However, the client remains liable for the co-payment at a later date C. Providers shall bill their usual and customary charge. For any service for which a copayment amount is imposed, the fiscal agent shall deduct the appropriate co-payment amount from the payment to the provider D. Physicians providing laboratory or radiology services in their office shall be responsible for collecting co-payments for the office visit and for the laboratory or radiology services provided.

6 P a ge 6 Colorado Psychiatric Access and Consultation for Kids (C-PACK) The Department is pleased to announce a valuable service to help providers manage psychiatric medications for children. The Department s Drug Utilization Review (DUR) provider, the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, in collaboration with Colorado Behavioral Health Systems, specifically the Colorado Psychiatric Access and Consultation for Kids (C-PACK) program, has child psychiatrists available to provide consultation to Medicaid providers. The service includes phone or consultations to optimize pharmacotherapy. Please contact Nila Mahyari, PharmD, DUR Clinical Specialist at Nila.Mahyari@state.co.us for additional information or to be connected with a child psychiatrist. Child psychiatrist responses are usually provided within a few days of the initial request. Care coordination is not a service provided by DUR. The program is designed for Colorado primary care providers serving children from birth to 19 years old. Currently, we are working in 2 regions: Denver Metro Area, and Southern Colorado. Providers may include: Pediatricians Family Physicians Nurse Practitioners Physician Assistants Certified Pediatric Nurse Practitioner Social Workers, Licensed Professional Counselors, and other mental health professionals who are colocated in primary settings School-based health providers C-PACK child psychiatrist offers curbside consultation to primary care providers who request a consultation. No Personal Health Information (PHI) is shared between the primary care doctor and the child psychiatrist. At this time, C-PACK does not include telepsychiatry or telemedicine where the child psychiatrist would video conference with the patient and/or family. In the C-PACK program, the primary care provider (PCP) is the medical professional treating the patient not the child psychiatrist. You may call C-PACK with general questions about children s and adolescent s behavioral health or about a specific patient. We are able to answer your questions about a variety of behavioral health topics: Diagnosing behavioral health conditions Medication Substance abuse School and childcare behavioral and learning difficulties Trauma, abuse, neglect Referrals to behavioral healthcare clinicians in the community Connecting to community resources

7 P a ge 7 Medicaid Cessation Resource Group Tobacco use remains the leading cause of preventable death and disease in Colorado, killing more than 5,100 Coloradans each year. Providers are one of the most influential forces in a smoker's life in providing encouragement and support towards the decision to quit. Medicaid tobacco treatment is comprehensively covered in Colorado, but current utilization of the counseling and pharmacotherapy benefits is low. The Colorado Department of Public Health and Environment (CDPHE) invites providers to participate in a new Medicaid Cessation Resource Group (MCRG) to support the integration of the Colorado Medicaid tobacco cessation counseling and pharmacotherapy benefits into clinical practice. Medicaid Cessation Resource Group members will help plan and discuss mechanisms and issues related to integrating care coordination efforts for Medicaid members and providers. Group members will be asked to provide their expertise via inperson (quarterly) and virtual (bi-monthly) meetings by: (1) Contributing to the assessment of current clinical workflow processes around tobacco interventions, (2) Collaborating on developing health care systems change processes, (3) Testing proposed monitoring systems and data collection/analysis, (4) Providing feedback on training materials and developing a communications plan, and (5) Participating in project evaluation activities. The first meeting is on Monday, November 2, All meetings will be held at CDPHE at: 4300 Cherry Creek Drive South, Glendale, CO Call-in numbers will be available for anyone unable to participate in person. Please contact Laura Gerard at Laura_Gerard@jsi.com or if interested in joining MCRG, the call-in number for the meeting, or for more information by Friday, October 23, 2015 so an accurate count of attendees can be planned for. Rate Increase Update Medicaid provider rate increases were approved during the legislative session and are effective for dates of service beginning July 1, All rates require approval from the Centers for Medicare and Medicaid Services (CMS). The Department has worked to obtain approval from CMS to implement the rates with an effective date of July 1, Some providers will be paid retroactively if there is a delay in rate implementation. Further rate increases will be implemented when approved. Please reference the Targeted Rate Increase Fact Sheet for more information. Morphine Equivalent Limitations Update Implementation of the morphine equivalent limitations policy is anticipated within the next few months. The Department is continuing to develop a policy for opioid-containing products and methadone that will apply a limit on the total daily milligrams of opioids and methadone that can be dispensed using morphine equivalents conversion calculations. Under this new policy, the daily milligrams of morphine equivalents for each opioid containing agent (including both long-acting and short-acting) and methadone that a member is currently taking will be added together. Prescriptions that exceed the maximum daily limit of 300 milligrams of morphine equivalents will be denied. In addition, the current policy that limits short-acting opioids to four (4) per day except for acute pain situations will continue to be in effect. Further details will be provided in future announcements.

8 P a ge 8 Care Coordination Corner By this time, ICHP is hopeful that all of our Practices have had an opportunity to meet and engage with the Care Coordinator assigned to the Practice. The ICHP Care Coordinators bring a depth of knowledge, not only of the Members themselves, but of the Practice and Community as a whole. The individual Care Coordinators come to you with a varied background of nursing, social work, community health workers and people with tons of knowledge and common sense. Each is deeply committed to ICHP and our Members. Much of the Care Coordination work is accomplished behind the scenes in your Practice. The Care Coordinators are there as a resource to your Practice and Members. They are able to help a Member solve most issues related to access to care, specialist referrals, transportation, food resources, community agencies, and many more needs that impact their health and well-being. The goal is to help Members learn to help themselves live a healthy life. As we begin our transition into fall, ICHP Care Coordinators continue to assist Members in the transitions of their lives. This includes transitions from acute care hospital stays, discharges from Skilled Nursing Facilities, releases from correctional facilities, leaving a shelter, becoming an adult or going off to college. We recognize that these transitions can be difficult, even scary, and want to help our Members achieve success in these transitions. Member Reattribution Coming soon, and ongoing on a quarterly basis, the Department will be reattributing a subset of ACC members who already have been assigned to a Primary Care Medical Provider (PCMP). While most ACC clients are attributed accurately to the primary care provider who they see for most of their general health care, this change will re-assign ACC clients who have changed their utilization patterns (perhaps because of a move or other life event) and whose recent claims data indicates that they are seeing a new provider for most of their primary care. This adjustment to our systematic attribution process will improve the accuracy of a provider's ACC panel by an average of 17%. This change will not impact any clients who made an active choice of their PCMP by calling HealthColorado. Affected clients will be notified of the change to their PCMP assignment by letter. The Accountable Care Collaborative (ACC) Program represents a committed effort to transform the Medicaid program into a system of better care for all its members, and to lower costs for the State of Colorado We re on the web:

9 P a ge 9 Colorado PAR New Vendor Notification eqhealth Solutions was selected by the Department of Health Care Policy and Financing to provide utilization management services for the ColoradoPAR Program beginning September 1, Together, eqhealth and HCPF will serve Medicaid members by focusing on and implementing the Department s mission to improve health care access and outcomes for the people we serve while demonstrating sound stewardship of financial resources. The current provider portal used to submit online PARs will be modernized to provide additional features and clarity for providers. In the coming months, please look for additional information regarding this transition in Provider Bulletins, the current provider portal (CareWebQI), on ColoradoPAR.com, and on the Department s ColoradoPAR Program website. Additionally, face-to-face training, webinars, and provider outreach campaigns are planned. The Colorado PAR Program reviews PARs for the following categories of services and supplies: o Audiology o Diagnostic imaging o Durable medical equipment (DME) o Inpatient out-of-state admissions o Medical services, including transplant and bariatric surgery o Physical & occupational therapy o Pediatric long term home health (LTHH) o Private duty nursing o Synagis o Vision There s New Healthcare in Town! Services Health Solutions is a healthcare organization in development in Pueblo, Las Animas, and Huerfano counties. Health Solutions, formerly Spanish Peaks Behavioral Health Centers, is evolving into a comprehensive healthcare service organization which includes: medical primary care services, physical therapy specializing in nonpharmaceutical pain management, community wellness education, activity education and therapy, horticulture education and therapy, employment services, nonmedical detoxification center, Suboxone opioid treatment clinic, and yes, full spectrum behavioral health services. Please join us for our upcoming quarterly Practice Managers Meetings on October 7th, and January 6th. You can join us in person at the Pueblo office, 503 North Main St. Suite #202 for valuable trainings and ICHP updates. Lunch will be served Please RSVP via to jessicaprovost@valueoptions.com or by calling 719/ with the number of attendees. Prenatal and Postpartum Care Services Approved: Increase to CPT codes as listed below: CPT increased to $ CPT increased to $ CPT increased to $593.10

Your guide to. Medicaid s Accountable Care Collaborative Program Rocky Mountain Health Plans

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