Fall 2013 Provider Workshops

1. Fall 2013 Provider Workshops

2. 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 Evaluation Agenda

3. On May 2, 2013, Governor Earl Ray Tomblin announced the expansion of the WV Medicaid Program. • Two major components: • Coverage to individuals aged 19 to 64 and former foster children making up to 138% of the Federal Poverty Level (FPL). • Expansion of Managed Care to include behavioral health, personal care and children’s dental services. Medicaid Expansion

4. 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. Impact of Medicaid Expansion

5. 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 64 Medicaid Expansion

6. 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 PERSONAL RESPONSIBILITY

7. 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. Medicaid Expansion

8. 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. Managed Care

9. Chapter 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 Updates to BMS Provider Manual

10. 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 Claim and Coding Updates

11. 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 Claim and Coding Updates

12. NATIONAL 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 CLAIM AND CODING UPDATES

13. 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. CLAIM AND CODING UPDATES

14. 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 (ICD10@wv.gov) • Check BMS webpage and newsletters in future for additional information • Looking for volunteers when ready to test CLAIM AND CODING UPDATES

15. ENHANCED 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. Program Updates

16. ENHANCED 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 Program Updates

17. 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 Program UPDATES

18. Health 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 PROGRAM UPDATES

19. WV 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. Program updates

20. 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-validationof 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 at this time Provider Enrollment and Screening

21. 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-validationstart date, providers will receive reminder letter that re-validationmust be completed within the next 30 days • 45 days after re-validationstart date, providers will receive reminder that if re-validationis not completed within next 15 days BMS may place provider on pay hold Provider Enrollment and Screening

22. 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: Scott.E.Winterfeld@wv.gov Recovery 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 AUDITS

23. 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) www.wvrecovery.com WV Medicaid partner Information