What s New. Submit Authorizations Online through Web Portal and Receive Real Time Responses, Including Automatic Authorizations!

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1 What s New Michigan Newsletter Summer 2014 Submit Authorizations Online through Web Portal and Receive Real Time Responses, Including Automatic Authorizations! What are the benefits? How does it work? Want to learn more? Easy to access 24/7 online access to Clear Coverage Receive real time authorization status by viewing your office s home page in Clear Coverage Automatic APPROVALS for many services Services not automatically approved are immediately uploaded into Molina Healthcare s authorization system and queued for clinical review Ability to upload medical records Verify member eligibility Ability to print proof of authorization Access Clear Coverage through the Molina Healthcare Provider Web Portal Take the online Clear Coverage training, which takes approximately 30 minutes to complete Schedule an on-site Clear Coverage Training by contacting your Provider Service Representative Visit the Molina Healthcare Provider Web Portal Contact your Provider Service Representative today If you have any questions or concerns, please contact Provider Services Department: Kelly Vetoich at (855) ext Monday through Friday between 8:00am and 5:00pm. Thank you for your continued services to Molina Healthcare members. In This Issue Submit Authorizations Online through Web Portal and Receive Real Time Responses, Including Automatic Authorizations!...1 Healthy Michigan Plan Health Risk Assessment & Provider Incentive...2 Michigan Care Improvement Registry (MCIR)...3 Smoking Cessation Counseling...3 Access to Care...4 Did you know?...4 Outpatient Parenteral Antibiotic Program (OPAT)...4 Deficit Reduction Act (DRA)...5 Evaluation & Management Service (E/M): Office Visits...6 HEDIS UPDATE...6 ICD-10: New Implementation Date!...6 Cellulitis...7 REMINDER!!...7 PCMH PCP Providers...7

2 Healthy Michigan Plan Health Risk Assessment & Provider Incentive Health Risk Assessment Healthy Michigan Plan members are required to complete a Health Risk Assessment (HRA) during their first PCP visit. This visit should be scheduled within 60 days of enrollment. Members receive a copy of the HRA in their Molina Welcome Packet. The Molina team is available to assist the member in completing the member sections. You may direct members to Molina Healthcare at (866) or TTY (800) , Monday through Friday between 9:00 am and 9:00 pm. Provider Incentive Initial Year of Healthy Michigan Enrollment Molina will reimburse the member s assigned Primary Care Physician (PCP) a $25 incentive for completing the Michigan Medicaid Healthy Michigan Plan (HMP) Health Risk Assessment (HRA) form. Molina will pay an additional $25 bonus if the member s PCP visit for the assessment is completed and a claim is billed to Molina within 150 days of enrollment. Molina s HRA payout criteria are as follows: To qualify for the incentive, provider will submit completed HRA to Molina. Incentives will be paid quarterly within 45 days of the quarter. For example, HRAs completed April to June, incentives will be paid by August 15. To receive the full $50 incentive, the HRA and a claim with qualifying visit billing code* must be completed by 150 days of enrollment. To qualify for the bonus, the member must be seen by a participating Physician/NP/PA within the same practice as the assigned PCP. If a member is seen by any other practitioner not in the assigned PCP practice, the incentive does not apply. The HRA incentive applies only to the member s first year of enrollment. For an HRA completed after 150 days of enrollment, Molina will pay $25. Please assure all sections of the HRA are complete when submitting, including Member ID, blood pressure reading, Provider NPI, etc. The NPI must be completed in order for Molina to validate the member s assigned PCP. If you have any questions, please call Molina Customer Service (855) Return the completed Health Risk Assessment to Molina Healthcare to our secured fax line at: (855) *A copy of the HRA form and qualifying visit billing codes can be found on the website at under Forms. 2 WHAT S NEW MICHIGAN NEWSLETTER

3 Michigan Care Improvement Registry (MCIR) MCIR is a nationally-recognized electronic statewide immunization registry that is accessible to both private and public providers. Public Act 91of 2006 expanded MCIR to extend immunization records into adulthood. Providers are highly encouraged to report adult immunizations to MCIR. Providers are still required to report childhood immunizations to MCIR within 72 hours of administration. MCIR saves time, money, and eliminates missed vaccination opportunities. Features include: Secure access via the web Provides immediate patient immunization history and what s due Recommends future dose dates Sends reminder and recall notices for due or overdue immunizations Provides quick and easy-to-print official immunization records for childcare and school requirements Busy practices have found that MCIR can: Simplify the ever-changing and complex immunization requirements and schedules involving different vaccine manufacturers and combination vaccines Help practices manage vaccine supply Accept electronic immunization information Generate a Profile Report to determine if it s necessary to increase immunization levels Public Health-related benefits to MCIR include: The all-hazard tracking system for emergency preparedness Links to other existing child health databases such as lead screening The Influenza Vaccine Exchange Network (IVEN) For more information, please contact your MCIR Regional Office or visit the website at Smoking Cessation Counseling Smoking and Tobacco Use Cessation (counseling to stop smoking and tobacco use is covered if ordered by a doctor). This includes two counseling attempts within a 12-month period. Each counseling attempt includes up to four face-to-face visits. Please use the following E&M Procedure Codes for smoking cessation when billing: WHAT S NEW MICHIGAN NEWSLETTER 3

4 Access to Care PCP Reminder!!! One of Molina s goals is to ensure that our members have 24/7 access to their primary care practitioner outside of regular hours of business. Please ensure that the following steps are being followed for after hour access, to keep members from unnecessarily going to the ER. Your after hour message should address the following for the member: Hang up and dial 911 or go to the ER (if necessary) Stay on the line to be connected Provide another number to reach the covering provider after hours Information to page the on-call provider How to reach an on-call physician: Phone number to contact providers after hours or Contact information for any providers who are covering for your practice Update your answering service to provide contact information for after hours care to the members Did you know? The Molina Healthcare Michigan Interactive Voice Response (IVR) system is here! This automated system will route providers to the department of their choice by selecting the appropriate prompt. Providers may dial to access the IVR system. The Molina Healthcare website offers a variety of useful tools for providers. Recently you may have noticed the I m a Health Care Professional link has moved. It is now located near the mid right section of the home page. Stay tuned for a big announcement in our Fall newsletter recipients of the Shining Star, Together Everyone Achieves More, Key to Success and Leading by Example awards. 4 WHAT S NEW MICHIGAN NEWSLETTER

5 Deficit Reduction Act (DRA) The DRA aims to cut fraud, waste and abuse from the Medicare and Medicaid programs. Molina Healthcare of Michigan maintains a comprehensive Fraud, Waste, and Abuse program. The program is held accountable for the special investigative process in accordance with federal and state statutes and regulations. Molina Healthcare of Michigan is dedicated to the detection, prevention, investigation, and reporting of potential health care fraud, waste, and abuse. As such, the Compliance department maintains a comprehensive plan, which addresses how Molina Healthcare of Michigan will uphold and follow state and federal statutes and regulations pertaining to fraud, waste, and abuse. The program also addresses fraud prevention and the education of appropriate employees, vendors, providers and associates doing business with Molina Healthcare of Michigan. Health care entities like Molina Healthcare of Michigan who receive or pay out at least $5 million dollars in Medicaid funds per year must comply with the DRA. As a contractor doing business with Molina Healthcare of Michigan, providers and their staff have the same obligation to report any actual or suspected violation of Medicare/Medicaid funds either by fraud, waste or abuse. Entities must have written policies that inform employees, contractors, and agents of the following: The Federal False Claims Act and state laws pertaining to submitting false claims How providers will detect and prevent fraud, waste, and abuse Employee protection rights as a whistleblowers The Federal False Claims Act and the Medicaid False Claims Act have Qui Tam language commonly referred to as whistleblower provisions. These provisions encourage employees (current or former) and others to report instances of fraud, waste or abuse to the government. The government may then proceed to file a lawsuit against the organization/individual accused of violating the False Claims acts. The whistleblower may also file a lawsuit independently. Cases found in favor of the government will result in the whistleblower receiving a portion of the amount awarded to the government. Whistleblower protections state that employees who have been discharged, demoted, suspended, threatened, harassed or otherwise discriminated against due to their role in disclosing or reporting a false claim are entitled to all relief necessary to make the employee whole including: Employment reinstatement at the same level of seniority Two times the amount of back pay plus interest Compensation for special damages incurred by the employee as a result of the employer s inappropriate actions Affected entities who fail to comply with the law will be at risk of forfeiting all Medicaid payments until compliance is met. Molina Healthcare will take steps to monitor Molina Healthcare of Michigan contracted providers to ensure compliance with the law. Molina maintains confidential reporting mechanisms that providers can use to report suspected fraud, waste, and abuse. The Molina Healthcare AlertLine is available 24/7 and can be reached at any time (day or night), over the weekend, or even on holidays. To report an issue by telephone, call toll-free at (866) To report an issue online, visit WHAT S NEW MICHIGAN NEWSLETTER 5

6 Evaluation & Management Service (E/M): Office Visits One of the hardest sections to code in the CPT manual is the Evaluation and Management section more specifically, the office visit codes: ( =New patient) and ( =Established patient). Three key elements need to be reviewed when making a coding decision: 1. History 2. Examination 3. Medical Decision Making Other elements that are considered when making an office visit code selection include counseling, coordination of care, nature of presenting problem, and time. Documentation must support the reason for the code choice. The Current Procedural Coding Manual, along with other resources that can be found via the internet or coding materials, can provide in-depth direction when making a code selection. HEDIS UPDATE NCQA now requires any information related to HEDIS results must be accompanied with proof of service. Documentation of proof of service may be in the form a progress note dated and signed by the provider with the date of service, type of service and the result or a copy of the original report containing the documented results. Example of documentation would include LDL, HbA1c, Bun, Creatinine, BMI, BP, Colonoscopy, Mammogram or Cervical Cancer Screen. ICD-10: New Implementation Date! The implementation of ICD-10 has been delayed for another year. The former date of implementation was October 1, 2014, and the new date of implementation is no sooner than October 1, Please continue to prepare for the new coding system. MDCH will allow the use of ICD-9 codes until September 30, Paper to Electronic (P2E) Currently paper claims are translated by Molina vendor Emdeon onto an ANSI X transaction and transmitted to Molina. As a result of this project paper claims will be translated by Molina vendor Emdeon onto an ANSI X transaction and transmitted to Molina. As a Part of P2E project, Molina is going to implement the Revised 1500 Claim Form v02/12. NUCC has released the revised 1500 Claim form v02/12 which will replace the current 1500 Claim form v08/05.the timelines for effective date for the use of the new form is in line with the P2E Project, and the 1500 project has already been rolled as sub project under Emdeon P2E Project. As a part of this project, Provider Communication is needed to notify the providers regarding the release of the new 1500 claim form v02/12 and the timelines associated with it. 6 WHAT S NEW MICHIGAN NEWSLETTER

7 Cellulitis Cellulitis is consistently in the top ten reasons for hospitalization across Medicaid and Medicare populations for Molina Healthcare in Michigan. Getting the right treatment early is one of the keys to improving the outcomes for these patients. For this reason, Molina will be partnering with Metro Infectious Disease Consultants (MIDC) to attempt to provide more timely evaluation of patients with cellulitis and other serious infections. MIDC is a group of 19 board certified Infectious Disease physicians with offices in Northville, Rochester Hills, Southgate, and Sterling Heights, providing care to patients ages MIDC has provided a single phone number, MIDC- USA, which will allow access to rapid consultative appointments - most being the same day in their offices! Our joint goal through this collaboration is to improve the timeliness and quality of care and enhance the services our members receive, thereby reducing the unnecessary use of emergency rooms leading to avoidable hospitalizations. Stay tuned for more details as we finalize and roll out this program. REMINDER!! PATIENT CENTERED MEDICAL HOME (PCMH) PCP PROVIDERS If you re PCMH Certified, and have not notified Molina Healthcare, please contact your Molina Healthcare, Provider Services Representative and they will assist you with information regarding your Molinacontract. We need your help! If you re currently PCMH Certified and have not sent your certificate to Molina, please fax it to Provider Services. Also, please remember if your PCMH Certified and your certifiation has expired, please fax us a copy of your current certificate. Our fax number is As always, please contact the Molina Provider Services Department at ext if you have questions regarding PCMH Certification. WHAT S NEW MICHIGAN NEWSLETTER 7

8 100 West Big Beaver Road, Suite 600 Troy, MI Molina Patients with Questions About Their Health? Call Our Nurse Advice Line! English: (888) Spanish: (866) OPEN 24 HOURS! Your family s health is our priority! For the hearing impaired, please call TTY (English): (866) TTY (Spanish): (866) or 711 Editor: Dawn Carerri Co-editor: Pam McCullough 42434MI0614