UniCare Health Plan of West Virginia, Inc. A true partnership with our provider community

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1 A true partnership with our provider community Medicaid Managed Care

2 Welcome! We would like to thank everyone for taking time out of their busy schedule to be here today! Thank you for the dedicated care and time you provide our UniCare members each day. 2

3 Provider Enrollment All providers who would like to offer services to Medicaid members are federally required to enroll and revalidate with West Virginia Medicaid through Molina Medicaid Solutions A provider s UniCare contract will be terminated and you will no longer be eligible to provide services to Medicaid members if enrollment with Molina is not completed per the federal guidelines. This enrollment does not authorize or require the provider to render services to non-mco/fee-forservice Medicaid members. 3

4 Provider education Resources available

5 Provider education materials UniCare provides a wide range of education materials for providers and their office staff: Provider manuals Clinical and policy guidelines Provider bulletins/updates Provider newsletters Reimbursement Policies Forms Health Education Material Quality Improvement Resources 5

6 Submitting claims Effective 6/1/17, timely filing is 180 days from Date of Service Submit via EDI: o EDI Payer ID #80314 o Technical Support: Phone: E-Solutions.Support@unicare.com Live chat: Submit paper claims to: o P.O. Box 91 Charleston, WV

7 Provider Orientation Webinars UniCare offers a monthly provider orientation webinar the third Tuesday of each month from 12:00 p.m.--1:00 p.m. Topic covered o Who we are o Health Care Management Services o Case Management o Community Outreach o Resources Available o Many more topics.. 7

8 Provider changes UniCare requires all providers, including hospitals, to send any administrative change requests to us so that we have correct information in our system. This includes changes in your practice or facility name, address, fax and information, tax identification number (TIN), and other similar changes. All providers with the exception of hospital-based providers must be credentialed. Submit the information via: o Fax: o ssbdatamanagementservices@anthem.com 8

9 Prenatal Risk Screening Instrument (PRSI) Effective January 1, 2017, UniCare is discontinuing our pregnancy notification form and adopting the West Virginia Prenatal Risk Screening Instrument(PRSI) The PRSI is intended to promote early and accurate identification of prenatal risk factors. Submit PRSI to UniCare within seven days of the first prenatal visit. o the completed form to prsi.unicare@anthem.com. Please type SECURE PRSI in the subject line. o Fax the completed form to

10 Clinic days These are designed to improve our compliance rates for preventive services. Our HEDIS results indicate a significant number of members are not receiving timely preventive services. Clinic days bring members and providers together to improve access to care and patient compliance. Appointment scheduling with members and providers will be coordinated by UniCare. In partnership with our network providers, clinic days will be hosted for members who have not received well-child visits or immunizations. Clinic days target members who are due for diabetes care or postpartum care. Members will be directed to the office of the provider identified as their PCP. 10

11 Availity Web Portal Expansion of our provider website services through Availity o Availity Web Portal ( a multi-payer website that gives physicians, hospitals and other health care professionals access to multiple payer information with a secure, single log-in o Availity s Web Portal offers a variety of online functions to help providers reduce administrative costs by eliminating paperwork and phone calls or faxes to obtain Prior Authorizations. o Target date for Access Point retirement: December

12 Availity Web Portal (cont.) Multiple payers, one website, one log-in o Claim status inquiry and claims submission o Eligibility and benefits check o Remittance advices retrieval o Monthly member rosters access o Prior Authorization requests, and responses o 24/7 availability from any computer with internet access o Real-time information exchange means highest accuracy of information o Free services for providers 12

13 Provider Online Reporting Tool PCP s can access the new reporting tool to retrieve monthly member rosters on Unicare s new provider web portal through Availity. If you haven t already, register for Unicare s provider web portal through Availity, you can do so at o How to register o Basic Navigation o Resource Available Requirement: Active Availity account 13

14 Utilization Management criteria Medicaid Managed Care 14

15 Medical Policies and Clinical UM Guidelines Outpatient procedures o T&A o Genetic testing o Spinal surgery Durable medical equipment o Wheelchairs o Life vests o Insulin pumps Home health care Physical/occupational/ speech therapy All policies are available at > Providers > State Sponsored Plan providers > West Virginia - Medicaid Managed Care. 15

16 AIM Specialty Health (AIM) Our nurses review requests for advanced imaging, cardiology, radiation therapy and sleep management services using AIM criteria. Both pediatric and adult guidelines are available and are separated by the area to be imaged. All policies are available at 185/index.html. Effective November 1, 2017, AIM s functions will increase. They will take over the management of prior authorization for advanced imaging, cardiology and radiation therapy services. 16

17 Interactive Care Reviewer (ICR) tool Medicaid Managed Care

18 Interactive Care Reviewer (ICR) Our ICR tool improves efficiency during the preapproval process. Physicians and facilities can submit medical and behavioral health preapproval requests for both outpatient and inpatient services. Ordering and servicing physicians and facilities can use the inquiry feature to find information on any preapproval affiliated with their TIN/organization. 18

19 ICR Overview Highlighted features include: View determination letters for the case. Save ordering and servicing providers to your favorites to easily populate provider information fields. Print a hard copy of a case or convert it to a PDF from the inquiry options. 19

20 Changes to prior authorization(pa) requests Claims must match what was entered in the PA request. To request a change, call or fax UM intake to make sure it s processed appropriately. Examples of items you may need to change include: An MRI without contrast to an MRI with contrast. The date(s) of service. You can make changes on the ICR tool as long as the service hasn t been rendered. If it has been rendered, please contact UM to make the change. 20

21 Coming Soon 4 th Quarter Provider Newsletter Educational Webinars Annual Provider Surveys Member Identification Number Change Online submission for provider changes 21

22 Questions? 22

23 Thank you for teaming up with UniCare Health Plan of West Virginia, Inc. 23