Fall 2013 Provider Workshops

FALL 2013 PROVIDER

WORKSHOPS

AGENDA Medicaid Expansion Policy Updates to BMS Provider Manual Claim and Coding Updates Program Updates Provider Enrollment and Screening Audits Medicaid Partner Information Automated Health Services Molina’s New Version of Health PAS Q&A’s, ICD-10 Survey & Workshop

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MEDICAID EXPANSION On May 2, 2013, Governor Earl Ray

Tomblin announced the expansion of the WV Medicaid Program.

Two major components:1. Coverage to individuals aged 19 to 64 and

former foster children making up to 138% of the Federal Poverty Level (FPL).

2. Expansion of Managed Care to include behavioral health, personal care and children’s dental services.

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IMPACT OF MEDICAID EXPANSION

Medicaid expansion will provide insurance coverage to more than 90,000 West Virginians.

Ends the disincentive to current Medicaid enrollees from working. Impoverished families can work to the middle class and no longer fear losing insurance coverage.

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MEDICAID EXPANSION West Virginia Medicaid currently serves:

Pregnant Women Children Very Low Income Families Aged/Blind/Disabled Medically Needy Populations

On October 1, 2013, WV Medicaid will begin enrolling the expanded population for coverage effective January 1, 2014:

Adults between 19 and 645

PERSONAL RESPONSIBILITY West Virginia will implement co-payments for

members enrolled in managed care beginning January 1, 2014.

Medicaid members not enrolled in managed care will not have co-payments.

Exempt from co-pays are: Pregnant Women; Children under 18; Individuals in

Nursing Homes, receiving Hospice, or covered through the Breast & Cervical Cancer Treatment Program

Emergency Services Family Planning Services

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MEDICAID EXPANSION In our current system we only cover non-

disabled adults up to 17% of FPL. Today, a family of four can only earn

approximately $3,700 a year. Starting on October 1 that same family can earn approximately $32,000 a year.

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MANAGED CARE Managed care is being expanded to

include behavioral health, personal care, and children’s dental.

Both the newly eligible (expansion) individuals and current Medicaid members enrolled in managed care will receive most of their Medicaid services through managed care.

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UPDATES TO BMS PROVIDER MANUALChapter 517 - Personal Care

Public Comment period extended to 9/4/13 Proposed changes include:

Fingerprint-based Criminal Background Checks Prior authorization of all hours

60 hours/240 units Submit Pre-Admissions Screening (PAS) tool and a

physician certification form to APS HealthCare for approval. 

Prior authorization for 61 hours/244 units to 210 hours/840 units will remain the same

Authorizations will be a maximum of 12 months. Will be phased in for members who are receiving

Personal Care services prior to implementation date

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CLAIM AND CODING UPDATES Reminder: Effective January 1, 2014, claim

payment via Electronic Funds Transfer (EFT) is required by Federal law EFT form(s) on Molina’s website Contact Molina for assistance

2012 ADA Claim Form Molina assessing date when system can accept 2012

ADA form Providers will need to include the following items on the

2012 ADA Claim Form for payment consideration: Place of Service Quantity or number of units Diagnosis codes and diagnosis-to-code pointers Multiple tooth surfaces

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CLAIM AND CODING UPDATES RENDERING PROVIDER INFORMATION REQUIRED EFFECTIVE JANUARY 1, 2014

Field 24J on CMS 1500 form will be required for each line item billed Enter NPI number of rendering provider for service billed on that line Line items without rendering provider information will be rejected

REFERRING PROVIDER INFORMATION REQUIRED – TARGET DATE 1ST QTR 2014

Claim Fields 17, 17a and 17b on CMS 1500 form required for referring provider information

Applies to specific types of service/providers, such as radiology and lab Current plan for claim processing:

Process claims without required referring provider information with warning message for limited period of time

At end of limited timeframe, activate edit to reject claims without required referring provider information

Watch BMS and Molina websites, provider newsletter for additional information in future

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CLAIM AND CODING UPDATESNATIONAL CORRECT CODING INITIATIVE (NCCI) Mandated by the Affordable Care Act of 2010 to incorporate NCCI into

Medicaid claims processing Procedure to Procedure (PTP) Edits Medically Unlikely Edits

Applies to CMS 1500 and outpatient hospital claims WV Medicaid implemented NCCI edits in summer 2012 Quarterly updates

Approximately 300,000 new same day surgery edits in October 2013 Activated in Medicare NCCI edits in July 2013

Appeals Appeals for PTP edits must be directed to CMS CMS permits BMS to review appeals for MUEs MUE Appeals should be sent to Molina

For more information on Medicaid NCCI, go to http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Data-and-Systems/National-Correct-Coding-Initiative.html

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CLAIM AND CODING UPDATES ICD-10 Providers, Payers & Vendors must be

compliant October 1, 2014! Per Centers for Medicare and Medicaid Services, if non-

compliant then: Claims may not be paid Face possible sanctions and/or penalties from Federal Office

of E-Health Standards and Services (OESS) for non-compliance with HIPAA

BMS workgroup currently assessing system, developing policy remediation plan, etc.

Code mapping began August 2013 and must be completed by November 2013.

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CLAIM AND CODING UPDATES ICD-10 cont’d. BMS now has ICD10 webpage on Molina’s website

Link on Molina website home page ICD-10 Webpage includes

WV Medicaid’s ICD-9 to ICD-10 transition Frequently asked questions ICD-10 countdown calendar Links to helpful resources such as webinars, CMS ICD-10 website

at http://www.cms.gov/Medicare/Coding/ICD10/ Email address for questions to WV Medicaid ICD-10 workgroup

([email protected]) Check BMS webpage and newsletters in future for additional

information Looking for volunteers when ready to test

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PROGRAM UPDATESENHANCED PAYMENTS FOR PRIMARY CARE PROVIDERS The Affordable Care Act (ACA) requires that Medicaid reimburse eligible

primary care providers at parity with Medicare rates in calendar years 2013 and 2014 for certain E&M and vaccination codes.

In order to receive the enhanced rate, eligible physicians and advanced practice registered nurses (APRNs) must complete a Self-Attestation Form. Physician Assistants (PAs) automatically qualify if their supervising physician qualifies and self-attests.

A provider must self-attest that he/she has a specialty or subspecialty designation of family medicine, general internal medicine, pediatric medicine, or one of the subspecialties outlined in the Provider’s Guide to Enhanced Primary Care Payments in West Virginia.

The Provider’s Guide, the 2013 enhance primary care and vaccine administration fee schedules, self-attestation forms and other guidelines can be found at http://www.dhhr.wv.gov/bms.

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PROGRAM UPDATESENHANCED PAYMENTS FOR PRIMARY CARE PROVIDERS cont’d. Approximately 844 providers are currently enrolled Enhanced payments began on July 12, 2013 for claims

received on and after that date Retroactive payments back to January 1, 2013, for enrolled

providers will begin soon Providers can self attest until December 31, 2013, for

enhanced payments for claims with dates of service in 2013 Providers must self- attest in January 2014 to be eligible for

enhanced payments for that calendar year

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PROGRAM UPDATES TAKE ME HOME WV Program to move eligible participants from long-term care

setting to home or community-based setting began accepting referrals on February 1, 2013

There are 112 active participants in the program, of which: 4 are pending eligibility determination 13 have been transitioned into the community 95 are still in the process of developing a transition plan and/or

looking for suitable housing

For more information, call Take Me Home, WV’s office staff at (304) 356-4926

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PROGRAM UPDATESHEALTH HOMES FOR MEMBERS WITH CHRONIC CONDITION Program is intended to improve the health of Medicaid members

who may need a variety of services to address primary and acute care, behavioral health care, and long-term care services. BMS has been working with stakeholders across the state To be eligible, Medicaid member must have Bipolar Disorder and be at risk for, or

have, Hepatitis B or C. Beginning in 6 counties: Cabell, Kanawha, Mercer, Putnam, Raleigh, Wayne

State Plan Amendment (SPA) to be submitted Six defined health home services

Comprehensive Care Management Care Coordination Health Promotion Comprehensive Transitional Care Individual and Family Support Services Referral to Community and Social Support Services

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PROGRAM UPDATESWV Clearance for Access: Registries and Employment Screening (WV CARES) WV CARES is WV’s grant-funded program under the

Affordable Care Act’s National Background Check Program WV is one of 24 State Medicaid Agencies participating in

national program at this time Centralized process for fitness determination of potential

employee in long term care setting BMS is currently reviewing WV specific web-based screens

for Registry Database Check State Criminal History Check Federal Criminal History Check

Will pilot with a few long-term care providers by end of year.

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PROVIDER ENROLLMENT AND SCREENING Provider enrollment and screening requirements

mandated by ACA CMS continues to provide guidance to states

Guidance remains pending on Criminal Background Check and Fingerprinting

Re-validation of providers began in June 2013 for physicians directly enrolled with Medicaid.

The second phase began earlier this month for approximately 1000 provider groups

Recent changes New deadline for re-validation of all WV Medicaid providers is

December 31, 2014. Anesthesiologist Assistants will not be eligible for enrollment

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PROVIDER ENROLLMENT AND SCREENING Providers will receive re-validation notice 1-2 weeks

prior to case number letter Letter with case number (online PEAP access code)

mailed at least 15 days prior to re-validation  start date Provider has total of 60 calendar days from start date

to re-enroll 30 days after re-validation start date, providers will

receive reminder letter that re-validation must be completed within the next 30 days

45 days after re-validation start date, providers will receive reminder that if re-validation is not completed within next 15 days BMS may place provider on pay hold

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AUDITS WV PAYMENT ERROR RATE MEASUREMENT (PERM) 2013 PERM 2013 Letters were mailed beginning last month WV Medicaid PERM Contact:

Scott Winterfeld, Office of Quality and Program Integrity

Telephone: 304-558-1700 or Email: [email protected] AUDIT CONTRACTOR (RAC) RAC Vendor is HMS First RAC letters to be mailed by October 1, 2013

Physicians providing pulmonary services MEDICAID INTEGRITY GROUP (MIG) Collaborative effort between CMS and BMS First MIG Letters will be mailed to Hospice Providers 22

WV MEDICAID PARTNER INFORMATION WV Bureau for Medical Services

Website at ww.dhhr.wv.gov/bms BMS Relationships

Molina – Fiscal Agent (FA) – claims processing, provider enrollment www.wvmmis.com

APS – Utilization Management Contractor (UMC) – prior authorization, case management www.apshealthcare.com

HMS – Recovery Audit Contractor (RAC) & Third Party Liability (TPL)

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