Enterprise Health Solutions (EHS) Processing Platform

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2 Enterprise Health Solutions (EHS) Processing Platform West Virginia Family Health Plan (WVFH) transitioned to the EHS claims processing platform on 1/1/18. The system transition will provide you with improved service and responsiveness by integrating resources and expertise into a single point. This upgrade, to an innovative and efficient system, will allow for timely, accurate payments and combined operations functionality. EHS updates are available on our website at If you have any questions about these changes, please call us at to speak directly with Provider Services. 2

3 Navinet Enhancements The following transaction are now available: Eligibility and Benefits Claims Status Inquiry Allowance Inquiry Cash Management EOB/Remittance Enhanced Provider Features transactions feature: Provider Directory NIA RadMD Authorizations Claims Investigations (no change from current process) Authorizations for J-codes ONLY Enhanced Provider Features * Availability may vary depending on your office type 3

4 Allowance Inquiry Allowance Inquiry allows you enter in the criteria to allow you to determine a Base Reimbursement* per Code/Modifier * Plan Design Coinsurance, Deductibles, & Limitations & Exclusions may affect actual rate paid 4

5 EOB and Remittance: Search This feature allows you to search by Billing Provider in 2 week increments. 6 months of history is kept in this section, too! Click in Billing Provider box to display the available selections. Next choose your beginning and ending date (no more than 14 days a time) 5

6 EOB and Remittance: Search Results Search results not only allow you to view by Statement Date, Provider #, Check #, & Check Amount, but you can also Download the PDF to save, print, or . 6

7 Appeal Request / Claim Dispute Step #1: Select New Request/Dispute Step #2: Choose your type of request 7

8 What will change for Providers? Member ID Cards Addresses (effective 1/1/2018) Medicaid General Correspondence: P.O. Box , Camp Hill, PA Medicaid Claims: P.O. Box , Camp Hill, PA Medicaid Checks: P.O. Box , Camp Hill, PA

9 New Explanation of Payment (EOP) Patient Information including benefit and member type information Claim Information billed services Basic payment information pricing detail, member cost share, etc. 9

10 WVFH Key Contact Claim Information Timely filing criteria: 365 calendar days after Date of Service, 180 days from primary payment or denial of claim EPSDT s for data reporting we prefer 60 days from the date of service Timely filing for denied authorization appeals is 90 days Timely filing for denied claim appeals is 180 days Include current practitioner information, such as your NPI Number on electronic claims Include current member information, such as WVFH Member ID number WVFH accepts electronic claims through Emdeon and Relay Health CPID and Payer ID

11 Consumer Assessment of Healthcare Providers and Systems (CAHPS) CAHPS measures a member s Measures involving providers: experience with their: Getting Needed Care Providers Getting Care Quickly Health Plan Coordination of Care Shared Decision Making Overall Health Care Health Promotion and Education Rating of Personal Doctor Rating of Specialist 11

12 Consumer Assessment of Healthcare Providers and Systems (CAHPS) What can providers do? Continue to provide excellent care Review WVFH s Accessibility Standards Work with your patient to make decisions about their health care Request that your patient keep you updated on care they receive from other providers Educate members on how to prevent illness and how they can be healthy 12

13 Consumer Assessment of Healthcare Providers and Systems (CAHPS) 13

14 MEDICATIONS TO REQUIRE MEDICAL PRIOR AUTHORIZATION EFFECTIVE MARCH 5TH, 2018 The prior authorization* process will apply to all West Virginia Family Health members. NaviNet is the most efficient means to request authorization for using autofill functionality. If you have trouble completing an authorization or have an issue with accessing NaviNet, contact your Provider Account Liaison. HCPCS codes requiring authorization on or After 3/5/18 J1300 J1561 J1745 J9355 J1322 J1566 J9042 J3490 J1459 J1568 J9228 J3590 J1556 J1569 J9271 J9999 J1557 J1572 J9299 J1561 J1599 J9305 *Outpatient services only. Authorization requests for the following medication classes / medications should be directed to the WV Rational Drug Therapy Program: Hemophilia, Spinraza, and Hepatitis C 14

15 WVFH Key Contact Claim Information WVFH Subcontractors Behavioral Health Beacon Vision Davis Vision In network claims must file electronically Dental United Concordia Dental (UCD) /Scion Member Services, Dental Referrals and Authorizations Radiology NIA Authorization Diagnostic Imaging contact Nurse Line (24/7 availability) For more information regarding Medical, Vision, and Dental contacts and mailing addresses, visit us online at 15

16 Behavioral Health Beacon John Marks - Program Director john.marks@beaconhs.com Sheila Kelly - Case Manager sheila.kelly@beaconhealthoptions.com Electronic BH Payer ID: Member Information, Claims, Authorizations Contact Beacon to assist with registering for eservices access Visit Beacon online at 16

17 Provider Resources Provider Services NaviNet Is The First Point of Contact phone claim review request fax line Jason Landers President jason.landers@highmark.com Lisa Shaffer - Senior Provider Contract Analyst lshaffer@gatewayhealthplan.com Kim Hammond - Manager Provider Relations khammond2@gatewayhealthplan.c om Jean Kranz - Director, Medicaid Operations jean.kranz@highmark.com Website Provider Manual, Directory (Audit Record), Bulletins, Policy & Procedures 17

18 Provider Account Liaison s Territories 18

19 WVFH Disease and Case Management Disease & Case Management - Providers and Member Referrals Welcome! Call WVFH at to reach our Case Management Department, Monday through Friday 8:30 am to 4:30 pm Case Managers work with members who have multiple chronic conditions, high coordination risk, frequent hospitalizations, high ED utilization, complex/special needs, high risk maternity needs, and/or transition management needs. Case managers focus on care coordination, collaboration, education, addressing care gaps, and patient self-management. Disease Management programs are aimed at improving the health outcomes for our members with COPD, Asthma, Cardiac Disease, and Diabetes. 19

20 WVFH Disease and Case Management Growing Up/EPSDT program is focused on identifying children s health problems early and to keep checking to be sure those children stay healthy. Mom Matters program offers support to pregnant members including ongoing care monitoring, evaluation, education and tailored interventions through pregnancy and up to one year post delivery. Wellness Coaches are available for targeted member inventions including a Nutritionist, Certified Diabetes Educator, and a Rehabilitative Coach. 20

21 WVFH Value Added Services and Wellness Rewards 2018 Wellness & Reward Incentives (Value Adds) for Member and Provider Maternity to Post Partum - Member $150 potential + Provider Incentive $200 PRSI DHHR notification by month 5 of pregnancy $50 member reward Well visit Adults and children - Member $25 annually Dental exam for 2-3 year old children $25 Member 24 Hour Nurse Line ( Diabetics ages who have completed the following three exams: HbA1C blood test, nephrology exam, and diabetic eye exam $50 Member Preventive dental care during pregnancy and 6 weeks postpartum Smoking Cessation Quit Line ( ) for members who are trying to quit smoking Phone Service Free cell phone with 9834) text, data, and voice 21

22 Questions? 22