What s New. Molina Healthcare of Michigan Opens West Michigan Office. Molina Healthcare West Michigan Newsletter Summer 2015

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1 What s New Molina Healthcare West Michigan Newsletter Summer 2015 Molina Healthcare of Michigan Opens West Michigan Office Molina Healthcare of Michigan officially opened its new office location in Grand Rapids on April 13, The office is located at 3196 Kraft Avenue and offers convenient access to 28th Street and I-96 Express Highway. The Grand Rapids area is home to a large number of our members and providers, said Stephen Harris, president of Molina Healthcare of Michigan. With this in mind, we are dedicated to displaying our commitment to these important stakeholders, as well as to our community partners, who are working with us to provide quality services to those we serve. This newest addition to the Molina Healthcare of Michigan offices will house approximately 15 employees in provider services, community outreach and provider engagement. In addition, remote employees who reside in the western part of the state will have access to the office without having to drive to the company s Michigan headquarters in Troy. In This Issue Molina Healthcare of Michigan Opens West Michigan Office... 1 Center for Integrative Medicine Molina Pay-for-Performance Program Improvements... 3 Molina Healthcare Appeals Process - Contracted Providers... 4 Laboratory Services... 5 Provider Information Changes... 5 Clear Coverage Online Authorization Tool... 5 Tips for Provider Claims Resolution... 6 Inhaled Corticosteroids Provider Update... 6 WebPortal Claims Enhancements... 7 Did You Know? Medicare Annual Comprehensive Exam (ACE) Program and Quality Bonus Payment Program... 8 Timely Prenatal Care Provider Bonus... 9 Healthy Michigan Plan Billing Correct Number of Units to Avoid MUE Edits ICD-10 Professional Testing Coding: Unlisted and Miscellaneous Codes Late-breaking News: Molina in the Community West Michigan Community Events Molina Healthcare of Michigan leaders including the Chief Medical Officer and Chief Operating Officer joined West Michigan employees to officially open the new office location. The April 13 ribbon-cutting ceremony and luncheon welcomed the West Michigan employees to their new home office in region.

2 Center for Integrative Medicine Molina is pleased to announce it will collaborate with the Center for Integrative Medicine (CIM) in Grand Rapids. Led by Dr. Corey Waller, the Center for Integrative Medicine provides a team based clinic so all patients are seen by both medical and social work professionals at every visit. For the unique members selected to participate in the program, CIM will treat the entire person address physical and psycho/social needs. To address the full range of the member needs, CIM sees patients on a weekly basis for the first 2-4 months. Appointments are generally 2 hours in length to assure all the patient needs are met. As a patient s conditions become more stable, CIM will schedule the appointments for every two weeks and then monthly. Medications are only written for the length of time between appointments. Patients can also be seen on a walk in basis if they are experiencing a crisis (either medical or behavioral health) and our providers (both medical and social work) are on call 24/7 so they can call after hours also if they are experiencing an emergency or crisis. Patients will keep their existing PCP. When the patient is stable and ready to return total care with their PCP, they will take over prescribing medications for the patient. Centers for Integrative Medicine will be a resource for the patient s PCP to help them understand their treatment plan and medication. CIM will also assist with ensuring the patient is connected with other needed services before transitioning them back to the PCP. If patients do not have a PCP, Molina will establish the patient with an appropriate PCP to ensure the patient can transition to a PCP s care once treatment at CIM is complete. The case manager(s) will help coordinate the patients care, arrange transportation to appointments and will follow up with patients if they no show or stop coming to CIM. 2 WHAT S NEW MOLINA HEALTHCARE OF WEST MICHIGAN NEWSLETTER

3 2015 Molina Pay-for-Performance Program Improvements Molina Healthcare Michigan recently sent out information to applicable participating providers for our 2015 Pay-for-Performance program. Since the program was introduced in 2011, Molina has paid out more than $15 million to physicians rewarding them for quality performance. For 2015, Molina has made the following changes to the program: The following measures have been removed from the HEDIS program and thus removed from the Molina program: o LDL-Screen o LDL-C Control Now that LDL measures are removed, providers will earn the additional Diabetic Care bonus of $200 by meeting only three measures: o Diabetic Eye Exam o HbA1C Good Control <8% (updated from <7%) o Nephropathy Screen (Micro albumin) Added the following measure for a reward of $25 for medication management for people with persistent asthma: o Use of Appropriate Medications for People with Persistent Asthma defined as one prescription annually for asthma control Age years Age years Added the following measure for a reward of $50 for timely prenatal care: o First prenatal visit performed in the first trimester (<13 weeks), or within 42 days if already pregnant at the time of enrollment. The annual ER bonus of 2% of all payments will remain in place for The targets remain the same: Region Internal Medicine Pediatrician Mixed Southeast MI- Region 1, 9, / / /1000 All Other Regions 936/ / /1000 The Molina team appreciates your collaboration and partnership for quality care of our members. We look forward to working with you to be successful in the Molina Pay-for-Performance program. If you have any questions, please contact your Provider Services Representative at (248) , ext See Page 9 for more information on the prenatal bonus. WHAT S NEW MOLINA HEALTHCARE OF WEST MICHIGAN NEWSLETTER 3

4 Molina Healthcare Appeals Process - Contracted Providers Following is the 2015 Molina Healthcare Michigan Appeals Process grid for contracted providers. This information is also available online at in the Provider Manual. Topic Contacts Process Claims Code Edit Appeals Administrative Denial Appeals 1 st level Administrative Denials pertain to medical authorizations Administrative Denial Appeals 2 nd level Medical Necessity Denial Appeals 1 st level Medical Necessity Denial Appeals 2 nd level Arbitration Questions relating to Code Edits contact: Customer Service Call Center (855) Fax to for Claims Appeals Related to: ü Code Editing ü Timely Filing ü Claim Disputes Questions relating to Appeals and Appeals status: Customer Service Call Center (855) Not Applicable Questions relating to Appeals and Appeals status: Customer Service Call Center for Providers (855) For Timely Filing Appeals and Code Edit Appeals, please use the Claims Dispute/Appeal Request Form located on the website. Additional notes for coding or timely filing: Fax request with supporting documentation & Claims Dispute/Appeal Request Form to (248) There are three levels of appeal Denial letters are sent within 30 days OR Paid claim (EOP) is statement of approval Post-service administrative denials. Submit written appeal within 90 days of the denial notification. Appeal must include new supporting evidence and/or documentation. A decision will be rendered and written notification will be provided within 30 calendar days of the receipt of a post-service appeal. Molina requires a claim be on file prior to submitting an appeal. There is only one level of appeal for administrative denials. Post-service Medical Necessity Denials. Examples include InterQual not met or request that did not meet medical criteria guidelines. Appeal process and timeframes are the same as administrative appeals above. If services have already been rendered, Molina requires a processed claim be on file before an appeal can be considered. Note: For Medicaid, there are no limits to the number of reconsiderations as long as the patient has not yet been discharged. For Medicare, after a decision is rendered, provider must file appeal (Medicare regulations). Appeal must state it is for 2nd Level review. The Medical Director will render a decision and written notification will be provided within 30 calendar days of the receipt of a post-service appeal. If services have already been rendered, Molina requires a processed claim be on file before an appeal can be considered. Note: For Medicaid, there are no limits to the number of reconsiderations as long as the patient has not yet been discharged. For Medicare, after a decision is rendered, provider must file appeal (Medicare regulations). For contracted providers, after all appeals processes have been exhausted, follow the binding arbitration process provisions of the Provider Agreement. 4 WHAT S NEW MOLINA HEALTHCARE OF WEST MICHIGAN NEWSLETTER

5 Laboratory Services Molina contracts with Quest Diagnostics and Joint Venture Hospital Laboratories (JVHL) for laboratory services. Genetic Testing There are exceptions for genetic testing, which requires an authorization. When obtaining authorization for genetic testing, please include the name of the laboratory which will perform the genetic test so that an authorization can be entered. Provider Information Changes Please remember to notify Molina of all provider changes. For general address, Tax ID, phone number changes, please utilize and follow the instructions on the Molina Provider Change Form found on the Provider Portal. Directions for completion and submission are provided on the top of the form. If you have questions, please contact your Provider Service Representative at (248) , ext Clear Coverage Online Authorization Tool Are you submitting prior authorizations via Clear Coverage, Molina Healthcare Michigan s online authorization tool? This user-friendly tool was developed in an effort to improve the quality of care our members receive and streamline processes for provider offices. The Clear Coverage online authorization tool simplifies the authorization process by improving turnaround times. This new application allows you to easily enter authorization information and have it loaded directly into our authorization system. This internet-based tool is accessed via the Provider Portal. Based on clinical information supplied, providers receive real-time responses in most instances. Don t delay! If you aren t already utilizing Clear Coverage, contact your Provider Service Representative at (248) , ext to find out more and schedule training. WHAT S NEW MOLINA HEALTHCARE OF WEST MICHIGAN NEWSLETTER 5

6 Tips for Provider Claims Resolution Please reference the following tips when seeking to resolve provider claims issues: Providers can find easy information on claims payments on the Molina WebPortal. Providers may call the Molina Customer Support Center at (855) for general claims questions. Some services require authorization and require formal appeal if authorization was not obtained. See the Utilization Management Section of the Provider Manual for appeals instructions: For the most current list of services/codes that require an authorization, please visit the Molina Provider Portal for the 2015 Codes Requiring Authorization file. o Note: Any procedures performed in the physician office, with the exception of unlisted or miscellaneous codes, do not require prior authorization. Inhaled Corticosteroids Provider Update Please review the following updates for inhaled corticosteroids: Qvar, Pulmicort Flexhaler, and Aerospan are now Molina Healthcare s preferred branded inhaled corticosteroid products. Effective April 1, 2015, Molina Healthcare members who have filled Asmanex in the past and are currently non-adherent to their treatment plan (no fills of Asmanex within 60 days identified from pharmacy claims) will receive a rejection for this medication at the network pharmacy. Qvar, Pulmicort Flexhaler or Aerospan will be required for trial on and after April 1, Members who are adherent and stable on Asmanex will be able to remain on Asmanex for the following three months with a grandfathered prior authorization. Please consider transition of Asmanex patients to Qvar, Pulmicort Flexhaler, or Aerospan, or submit a prior authorization documenting the need to continue Asmanex in the future. Physicians whose members meet criteria for a grandfathered prior authorization will receive a letter in June 2015 listing Asmanex adherent members. This will serve as a reminder to submit a request to continue Asmanex or transition the member to Qvar, Pulmicort Flexhaler, or Aerospan. Effective April 1, 2015, Qvar, Pulmicort Flexhaler, or Aerospan will be required for all new starts of inhaled corticosteroid prescriptions. If you need any additional information, please contact the Molina Pharmacy Department at (888) WHAT S NEW MOLINA HEALTHCARE OF WEST MICHIGAN NEWSLETTER

7 WebPortal Claims Enhancements If you ve been on the Molina WebPortal recently, you ll notice we ve been working hard to make enhancements and empower our provider offices to accomplish more through the portal. In the last few weeks, the following enhancements were implemented for claims on the WebPortal: 1) Ability to create a template for most created claims 2) Ability to save claims for batch submission and ability to submit more than one claim at the same time 3) Ability to correct a claim 4) Ability to void a claim 5) Ability to attach supporting documents to new claims, corrected claims, and pended claims If you have questions or need an access code or training for the WebPortal, please contact your Provider Service Representative. Did You Know? üü Based on their enrollment date, Healthy Michigan Plan (HMP) members are due annually for a Health Risk Assessment (HRA). Providers will receive an annual bonus of $25 for each completed HRA. üü When faxing an appeal, be sure to send it to the fax number indicated on the denial letter. Send applicable sections of the medical record that provide the information that supports your case to be approved; i.e., information that counters the reason for denial (test results, reason for not prior authorizing, etc.) üü To check Member Eligibility, log in to the Provider Portal. For additional training on the Provider Portal, please contact your Provider Service Representative. üü To view Claims information on the Provider Portal, appropriate access must be granted through your provider administrator. WHAT S NEW MOLINA HEALTHCARE OF WEST MICHIGAN NEWSLETTER 7

8 2015 Medicare Annual Comprehensive Exam (ACE) Program and Quality Bonus Payment Program The Molina Healthcare Medicare ACE program started Feb. 1, The ACE program is part of the Molina Quality Bonus Payment Program. This program includes the ACE and Quality Measurements. The ACE provider packets for all of your Molina Medicare members have been mailed and/or hand delivered to your Clinical Director/Site Manager. ACE Highlights All visits MUST be completed on or before June 30, 2015 Providers will receive a $250 incentive for ACE visits completed by June 30, 2015 and forms submitted by July 15, 2015 Providers can receive up to an additional $100 in Quality Bonus Payment for each ACE form that has a member s historic chronic conditions re-assessed with documented treatment plans Payments for submitted ACE forms are sent to providers monthly as received and verified for completeness Allow up to an hour to complete the exam either by the physician (FP, IM, DO) or qualified clinician (PA, PA-C, NP, NP-C) Conduct a complete health assessment using the Molina Medicare Annual Comprehensive Exam (ACE) form or from your Electronic Medical Record (EMR) which includes all of the elements Be certain to address EACH hierarchal chronic condition (HCC) listed on the ACE form as currently present or no longer present Ensure accuracy and complete capture of ALL diagnoses when completing forms Remember ALL completed assessments are kept in the patient s files, as they are part of the medical record Submit claim for the office visit in the normal course of business in order to receive the payment for service rendered. The incentive payment is in addition to your claim payment. Member Incentive To assist our provider community in their efforts in completing the exams, Molina Medicare members will receive a $15 gift card once their PCP returns an ACE form. To ensure that members receive their gift cards in a timely manner, please complete and fax ACE forms to Molina as soon as possible Members should contact member services at (800) for incentive questions Helpful Reminders Submit all Medicare ACE forms and any supporting documentation to Molina Medicare via fax to (877) Please note that the $250 assessment incentive is awarded only upon correct completion and submission of Medicare ACE form. Member reward incentives are only issued upon confirmation of correctly completed 2015 ACE form. NOTE: To avoid confusion, this program is NOT associated with the HRA Healthy MI program. If you have any questions regarding your ACE packets, please contact Jonathan Quinley at (888) ext WHAT S NEW MOLINA HEALTHCARE OF WEST MICHIGAN NEWSLETTER

9 Timely Prenatal Care Provider Bonus Molina Healthcare Michigan appreciates provider assistance in assuring Molina members are receiving prompt prenatal and post-partum care, documented through individual visit claims submission to meet MDCH s HEDIS data reporting requirements. New to the Pay-for-Performance Program in 2015, Molina is offering a bonus for timely prenatal care. This bonus will support the need for pregnant members, whether new to Molina or current members who may become pregnant, to receive timely prenatal care. The parameters are care within 42 days of enrollment for new members and in the first trimester for currently enrolled members. Molina will now pay the following additional bonus to OB/GYN and primary care providers beginning with care provided Jan. 1, The bonus will be paid quarterly after delivery. As a reminder, Molina requires individual (non-global) service billing to meet HEDIS data reporting requirements. Molina will automatically calculate the bonus based on the date of delivery. There is no additional action on the part of the physician to receive this bonus. OBSTETRICAL CARE BONUS PAYMENT 59425, $50 Performed in the first trimester (<13 weeks), or within 42 days if already pregnant at the time of enrollment. Prenatal Care All ages Antepartum Care Noted below are Molina s scores on the Timelines of Prenatal Care and Postpartum Care. Molina s Prenatal Care Measure is significantly below the Medicaid 75th and 90th national benchmark percentiles. Measure/Indicator 2014 Molina Rate 2013 National Benchmark 75 th Percentile 2013 National Benchmark 90 th Percentile Timeliness of 83.63% 89.72% 92.82% Prenatal Care 1 1 HEDIS guideline Member must receive a prenatal care visit as a member of the organization in the first trimester or within 42 days of enrollment in the organization. Molina Healthcare of Michigan looks forward to rewarding providers for their support of this important quality care initiative. WHAT S NEW MOLINA HEALTHCARE OF WEST MICHIGAN NEWSLETTER 9

10 Healthy Michigan Plan Healthy Michigan Plan (HMP) is the Medicaid expansion program that began April 1, Currently, Molina Healthcare has 51,370 Healthy Michigan members. Some of the key provisions of the Healthy Michigan program are: Access to care with an initial enrollee PCP visit within 150 days of enrollment; Enrollee commitment to healthy lifestyle; and Completion of an annual Health Risk Appraisal (HRA). Molina rewards physicians in the Healthy Michigan program: $25 for completion of the HRA (initial or annual) $50 for completion of the HRA if the visit occurred within 150 days of enrollment Checks are mailed monthly once the HRA is deemed complete Molina congratulates physicians for providing prompt access to care for Healthy Micigan membes. To date, 31,880 Healthy Michigan Members have had a PCP visit. However, only about 5,100 of these members have had an office visit with a completed HRA. To receive your full rewards on the Healthy Michigan program, please continue to complete the HRA and send the information via: Fax completed HRAs to our secured fax line at: (855) Mail to: Molina Healthcare of Michigan 880 W. Long Lake Rd, Suite 600 Troy, MI Attn: Quality Management Department Healthy Michigan members are identified as such on your monthly enrollment list. A copy of the standard HRA is available on the Molina WebPortal. 10 WHAT S NEW MOLINA HEALTHCARE OF WEST MICHIGAN NEWSLETTER

11 Billing Correct Number of Units to Avoid MUE Edits Correct billing of units with HCPCS/CPT codes still apply even when receiving an agreed flat or case rate reimbursement for services. CMS developed Medically Unlikely Edits (MUEs) to reduce the paid claims error rate for Part B claims. An MUE for a HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service. All HCPCS/CPT codes do not have an MUE. Billing the appropriate units will ensure appropriate trending, medical record maintenance, and avoid the MUE edits. ICD-10 Professional Testing The ICD-10 implementation date is quickly approaching. ICD-10 will affect diagnosis and inpatient procedure coding for everyone covered by Health Insurance Portability and Accountability Act (HIPAA), not just those who submit Medicare or Medicaid claims. The change to ICD-10 does not affect CPT coding for outpatient procedures. Molina has initiated a project to ensure our readiness with the mandated deadline. Molina is interested in coordinating with providers and facilities to help understand and mitigate potential impacts through integrated testing as the industry upgrades to ICD-10. We encourage you to use our ICD-10 testing tool for professional health care providers. The testing tool will not only give you an opportunity to work with ICD-10, but it also will provide us with a better idea of ICD-10 readiness. The tool can be accessed through the following link (no special software is required): For more information about ICD-10, visit the following link for FAQs: Providers with specific questions can be directed via to Molina.ICD-10@. We will also continue to post updates regarding the ICD-10 upgrade as well as information relevant to our provider community on our website at WHAT S NEW MOLINA HEALTHCARE OF WEST MICHIGAN NEWSLETTER 11

12 Coding: Unlisted and Miscellaneous Codes According to the 2015 Molina Prior Authorization/Pre-Service Review Guide, ALL Unlisted and Miscellaneous Codes must be prior authorized. Supporting medical necessity documentation and rationale must be submitted with the prior authorization request. Note: Participating providers can perform all procedures in the office without an authorization, except for unlisted miscellaneous codes. Unlisted and miscellaneous codes, regardless of place of service, require authorization. Late-breaking News: Molina to Acquire Medicaid and MIChild Assets of HealthPlus in Michigan Molina Healthcare, Inc. and HealthPlus of Michigan, Inc. jointly announced May 15 that Molina Healthcare of Michigan has entered into a definitive agreement to acquire certain assets of the Medicaid and MIChild business of HealthPlus of Michigan and its subsidiary, HealthPlus Partners, Inc. As a part of the transaction, Molina Healthcare of Michigan will assume HealthPlus Partners Medicaid contract and HealthPlus of Michigan s MIChild contract, as well as certain provider agreements. HealthPlus Partners and HealthPlus of Michigan currently arrange for healthcare services for approximately 90,000 Medicaid and 6,000 MIChild patients. Subject to regulatory approvals and the satisfaction of other closing conditions, the closing of the transaction is expected to occur during the third quarter of Look for more details in the next issue of What s New. 12 WHAT S NEW MOLINA HEALTHCARE OF WEST MICHIGAN NEWSLETTER

13 Molina in the Community Calling All Community Champions Molina Healthcare is looking to award four unsung heroes who have gone above and beyond the call of duty volunteering and helping those in the West Michigan Community. The Community Champions Awards were created in honor of Dr. C. David Molina to shine light on the sometimes overshadowed heroes in our community. Each Community Champion is awarded a $1,000 grant to donate to the non-profit of their choice. This year we are searching for four new champions to award in the West Michigan area. Molina Healthcare of Michigan will host the first annual West Michigan Community Champions to be held in Grand Rapids this coming fall. If you know of a local hero deserving of a Community Champion Award please contact us! Please write a detailed summary explaining why you believe that person would be a great candidate for a Molina Healthcare Community Champion Award, and to Benicia.Kyle@MolinaHealthCare.Com. West Michigan Community Events Caption: Molina Healthcare Community Champion 2014 Connie Navarro of Muskegon County accepts her award. Mrs. Navarro is co-founder of the non-profit "Latinos Working for the Future", whose mission is to promote and educate the community on Latino and low income issues. July & August, Every Wednesday, 9 a.m. to noon Holland Farmer s Market July 2, 16 & 30, 9 a.m. to noon North End Community Outreach Ministries Molina education July 8, 3 p.m. to 7 p.m. United Community Outreach Ministries (UCOM) Carnival July 10, 14 & 28, 5 p.m. to 9 p.m. Hot Summer Nights Kroc Center August El Informador - Backpack Giveaway August 11, noon to 4 p.m. Reading for Rides Kent County Youth Fair in Lowell in conjunction with Kent County 4-H and MSU Extension August 15 Celebration National Health Center Week Muskegon Family Care August 29, 11 a.m. to 1 p.m. West End CRC - Backpack Festival August 5, 4 p.m. to 9 p.m. National Night out at the Kroc Center WHAT S NEW MOLINA HEALTHCARE OF WEST MICHIGAN NEWSLETTER 13

14 880 West Long Lake Road, Suite 600 Troy, MI MI0415