Provider Newsletter October-December 2017

Transcription

1 Provider Newsletter October-December 2017

2 Table of Contents Contact Information... 3 HAP Midwest Health Plan Access and Availability Standards... 3 Provider Enrollment in CHAMPS Requirement... 4 Claims... 4 MIHP Procedure Codes... 4 Claim Submission Guidelines... 4 Provider Pay for Performance 2017 Reminder... 5 Case Management... 5 Maternal Infant Health Program... 5 HAP Midwest Medicaid and MMP Drug Formularies... 5 Medicare-Medicaid Plan (MMP) Formulary... 6 Medicaid Formulary... 6 Partnership Between Behavioral Health Care and Medical Health Care... 6 MI Marketplace Option Provider Education... 7 Michigan Care Improvement Registry (MCIR)... 7 Vaccines for Children (VFC)... 7 Reporting Communicable Diseases... 7 MQIC Mobile App... 7 Lead Removal... 7 Lead Screening... 8 Questions about HAP Midwest Health Plan?

3 Contact Information For Contact Claims questions (888) , option 2, 2 Changes in: Robin Owczarzak Office addresses Remittance payment addresses Demographic changes Phone: Fax: (313) (313) rowczarzak@midwesthealthplan.com Adding a provider to your office Leslie Linares Phone: (313) Fax: (313) llinares@midwesthealthplan.com Other operational issues Provider Services Suzanne Kayner: skayner@hap.org Peggy O Neil: poneil@hap.org Medicaid efax (248) Medicare efax (248) HAP Midwest Health Plan Access and Availability Standards Per the HAP Midwest Health Plan contract all providers must follow the Access and Availability Standards as outlined in the table below. Accessibility of Services: Service will be provided in the appropriate time frame Appointment lead time: Primary Care Preventive (well) care care provided in Within 14 calendar days asymptomatic situations to prevent the occurrence or progression of conditions. Routine care care provided in symptomatic nonurgent conditions. Within 14 calendar days Urgent care care for serious, but nonemergency Same or next calendar day (< 48 hours) injury or illness. After hours care Physicians or their designee shall be available by telephone twenty-four (24) hours per day, seven (7) days per week. Wait time in the office length of time before the Less than 30 minutes member is seen by the provider after checking in with the receptionist. Accessibility of Services: Service will be provided in the appropriate time frame Appointment lead time: High Volume Specialist and High Impact Specialist Non-Urgent with symptoms Routine without symptoms Urgent care care for serious, but nonemergency injury or illness. Within 15 calendar days Within 60 calendar days Same or next calendar day (<48 hours) 3

4 Provider Enrollment in CHAMPS Requirement Effective January 1, 2018, the Michigan Department of Health and Human Services states that any individual or entity that provides services to, or orders, prescribes, refers or certifies eligibility for services for, individuals who are eligible for medical assistance under the State Plan participating in a managed care organization s provider network are required to be screened and enrolled in the Michigan Medicaid Program. Managed Care Organization providers furnishing services to Medicaid beneficiaries must enroll in CHAMPS. Medicaid rules prohibit payment to providers not appropriately screened and enrolled. Additional information can be found in MSA policy bulletin on the MDHHS website. Providers are encouraged to verify if a referring or ordering provider is enrolled with Michigan Medicaid prior to rendering services. You can do this with the CHAMPS Provider Verification Tool. Visit michigan.gov and search for Provider Verification Tool Instructions. Claims Please see below for MIHP billing guidelines: MIHP Procedure Codes HCPCS Code Short Description HCPCS Action Maximum Comments Providers must bill this code as two Interv Hlth/Behav Fam w/pt $40.51 units to receive the total fee of $81.02 per policy. *99402 Preventive Counseling Indv $60.72 Visit in office *99402 Preventive Counseling Indv $83.72 Visit in home H1000 Prenatal Care Atrisk Assessm $79.91 Maternal assessment in office H2000 Comp Multidiscipline Evaluation $99.07 Assessment in home S9442 Birthing class $29.46 S9443 Lactation class $49.92 S9444 Parenting class $39.46 T1023 Program Intake Assessment $79.91 Infant assessment in office * is utilized for all MIHP visits occurring in the home, office or places other than the home. Home visits are reimbursed at a different rate than clinic visits. To receive appropriate reimbursement for visits, it is important to include the place of service when billing these codes. Reimbursement for visits will be determined by the place of service code entered on the claim. For purposes of billing, a visit must be a minimum of 30 minutes in length. Claim Submission Guidelines To ensure correct benefit coverage and accurate claim adjudication do not submit single claims that date span across years. Please follow the guidelines below. CMS 1500 Form 24a. Dates of service billing Report all services provided on the same day for the same patient using only one claim form. Enter the month, day and year for each procedure, using the format "MMDDYY." UB-04 Form Statement Covers Period (Form Locator 6) Report all services provided to the same patient using only one claim form. Enter both from and through dates using the format "MMDDYY." 4

5 Provider Pay for Performance 2017 Reminder HAP Midwest will award a $300 bonus to our practices for each child who has the following vaccines completed by their second birthday: DTaP (4 doses) Hib (3 doses) PCV (4 doses) MMR (1 dose between first and second birthday) IPV (3 doses) VZV (1 dose between first and second birthday) Hepatitis B (3 doses) Case Management The HAP Midwest Complex Case Management program provides coordination of care and services to members who have experienced a critical event or diagnosis that requires the extensive use of resources and who need help navigating the system to facilitate appropriate delivery of care and services. To refer a member to this program, call (800) Maternal Infant Health Program HAP Midwest Health Plan Population Served: - Medicaid - Children Special Health Care Services - Dual Eligible - Healthy Michigan Plan HAP Midwest Service Area Region 6 counties: - Genesee, Huron, Lapeer, Sanilac, Shiawassee, St. Clair and Tuscola Pre-Natal Care HAP Midwest addresses and supports the importance of pre-natal care for members by referring them to the Maternal Infant Health Program monthly. Members are referred to participating providers in their local communities. Members are also referred to HAP Midwest s vendor, Optum, for the HAP Midwest Maternity program and First Year of Life. With the maternity program, members are: Contacted by phone. Offered support through the 24-hour nurse line. Provided educational materials and one on one communication. Post-Partum Packets Eligible new members receive a congratulatory letter and welcome packet explaining the different incentives HAP Midwest offers to them and their child. We follow up with the new moms to ensure they ve received the packet and answer any questions. There are incentives for new moms to take a depression screening as well as visit their OB/GYN for a post-partum check within days after the birth of their child. HAP Midwest Medicaid and MMP Drug Formularies Changes to the HAP Midwest drug formularies are effective January 1. Visit hap.org/midwest for drug formularies, along with updates and changes, including: Restrictions and preferences An explanation of limits How to use the formulary How to submit an exception request Generic drugs Step therapy Prior authorization 5

6 You can use the search tool to check the status of a specific drug or look at a drug category. You can also view or print the complete formulary. A printed copy of the drug formulary, or related documents, is also available upon request. We post drug formularies on our website annually and updates throughout the year. Negative formulary changes are changes that result in restrictions or replacements, which may include prior authorization, step therapy, quantity limits or tier level changes. We mail a letter to affected members. Their practitioner also receives a letter and a patient list. Medicare-Medicaid Plan (MMP) Formulary The 2017 and 2018 HAP Midwest MI Health Link (MMP) formularies are available at hap.org/midwest. You can search alphabetically or by type of drug. The drug formulary may change every year on January 1 and throughout the year. Medicaid Formulary HAP Midwest participates in the Michigan Medicaid Health Plan Common Formulary. General information about the common formulary and a history of formulary changes can be found at hap.org/midwest. Partnership Between Behavioral Health Care and Medical Health Care If you have patients with behavioral health needs and you are unsure of where to turn, we have good news! We realize that continuity and coordination of care is an important aspect of caring for members. In the past, coordination of care between medical care and behavioral health care was extremely difficult due to lack of open lines of communication. Recognizing the need for greater collaboration between the Medicaid Health Plans and the Prepaid Inpatient Health Plans regional administrative entities for community mental health services the MDHHS mandated that they work together to improve the integration of physical and behavioral health care. As such, the PIHPs and MHPs began meeting to establish joint care planning processes for information sharing and coordination of care for shared members. HAP Midwest shares counties with two PIHPs: Mid State Health Network (MSHN: Shiawassee, Tuscola, and Huron counties) Region 10 (Genesee, Lapeer, Sanilac, and St. Clair counties). Workgroups were formed to develop processes for coordination and continuity of care. Care coordination meetings started in late Monthly meetings continue to be held today. Care Coordinators from MSHN, Region 10 and HAP Midwest develop care plans on mutual members and document on a shared web-based care management system. In addition to the care coordination meetings, a state level workgroup meets twice monthly with representation from the MHPs, PIHPs and MDHHS. This workgroup discusses quality improvement processes and other aspects of moving the project forward. Currently, this workgroup is finalizing a process for hospitalization notification between the MHPs and PIHPs. If one of your Medicaid patients needs behavioral health care, they can be referred to a HAP Midwest mental health practitioner. If they have more comprehensive needs or require inpatient hospitalization, they can contact one of the PIHPs for an intake assessment. You can contact them as follows: Region 10: Genesee County: (877) Lapeer, Sanilac, or St. Clair Counties: (888) Mid-State Health Network (MSHN) Main Access/Utilization Management Line: (844) , option 1 6

7 MI Marketplace Option Provider Education Beginning April 2018, MDHHS will begin transitioning eligible beneficiaries from the Healthy Michigan Plan to a MI Marketplace Option health plan. The MI Marketplace Option health plans are not Medicaid health plans and will provide a limited benefit package. For more information and training, go to michigan.gov/medicaidproviders and select Policy, Letters & Forms, Numbered Letters, 2017, L Michigan Care Improvement Registry (MCIR) Per your contract with HAP Midwest Health Plan and Public Act 91 of 2006, all immunization providers are required to report childhood immunizations to MCIR. This affects immunizations administered to persons born Jan. 1, 1994 to present. If you need information on reporting or access call (888) or visit mcir.org. They can also assist you in improving your immunization rates by using MCIR to run batch reports and monthly immunization recall letters. Vaccines for Children (VFC) As a Medicaid provider, you are required to get your vaccines through the VFC program. The Alliance for Immunization in Michigan (AIM) tool kits include information on VFC and MCIR as well as catch up schedules, storage information, vaccine information sheets and more! Contact your local health department if you have questions about the VFC program. The AIM tool kit can be found at aimtoolkit.org. Reporting Communicable Diseases State law requires providers to report all communicable diseases to the local health department. The AIM Provider Tool Kit includes a helpful brochure titled Table of Reportable Diseases in Michigan. Copies of the brochure and other information can be found at aimtoolkit.org. MQIC Mobile App The Michigan Quality Improvement Consortium (MQIC) has an app for all Android and ios smartphones that features evidence based clinical practice guidelines and useful tools. To be up to date on the most recent announcements and news, download the app now. Visit your app store and search for MQIC. You can select from different categories on the home screen that are best suited for your practice. Lead Removal Many providers are familiar with lead screening guidelines. Most people in Michigan know about the lead pipes in Flint and the efforts to make the Flint residents safe from lead exposure. But not everyone may know that the MDHHS has a program to help families lead proof their homes. Individuals and families meeting the criteria below may be eligible for grants to remove lead from their homes. Have a child under age six or a pregnant female living in the home Are a low-to-moderate income family Live in a home built before 1978 Live in the counties of Genesee, Ingham, Jackson, Kalamazoo, Kent, Lenawee, Macomb, Oakland, Saginaw, or the city of Detroit OR elsewhere if your child has a lead level of 5 or above Own or rent the home (Information on criteria was taken from michigan.gov.) Families meeting these criteria can apply for the grant by visiting: For Arabic and Spanish: If you have any questions call (866)

8 Lead Screening Michigan State law requires all Medicaid-enrolled children between the ages of 12 and 24 months or 36 and 72 months have a blood lead test. The Healthcare Effectiveness Data and Information Set (HEDIS ) lead screening measure requires that children receive a blood lead screening on or before their second birthday. Medical record documentation needs to include the date of service and the result of the blood lead screen. Provider offices may also enter the results of blood lead screening into MCIR to reduce onsite medical record review. HAP Midwest has had Lead Testing in Children as a Preventive Health Indicator for several years and continues to monitor it monthly. We ensure all new members receive health guidelines for lead testing. Reminder mailings are sent to parents quarterly. Providers are notified via the Opportunities Report of children due for lead screening. This report is updated monthly. All new moms also receive lead poisoning and testing information. Questions about HAP Midwest Health Plan? You can always call us at (888) for more information. We also have the following information posted online at hap.org/midwest. If you prefer a hard copy, call the number listed above and we will mail it to you. Affirmative statement about UM incentives Complex case management Coordination of Care between Behavioral Health and Primary Care Providers Covered and non-covered benefits Credentialing information Fraud, Waste and Abuse Information Disease management services Evaluation of medical technology HAP Midwest s policy for making an appropriate practitioner reviewer available to discuss any utilization management denial decision and how to contact a reviewer Member rights and responsibilities Network limits Pharmacy procedures and formularies Privacy and HIPAA information Utilization management criteria HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). 8