WEST VIRGINIA FAMILY HEALTH
PROVIDER MANUAL
West Virginia Family Health is a managed care organization
based in West Virginia providing services to Medicaid
beneficiaries. Highmark West Virginia has contracted a network
of providers to service the Medicaid population for West Virginia
Family Health. This partnership provides an opportunity to
create a more effective care delivery system and improve the
overall health of West Virginia Medicaid recipients.
APRIL 2016
WEST VIRGINIA FAMILY HEALTH PROVIDER MANUAL
TABLE OF CONTENTS
CHAPTER/UNIT
TOPIC
Quick Reference
Introduction
CHAPTER 1 MEMBER ENROLLMENT AND BENEFITS
1.1 Enrollment and Eligibility
• Enrollment Process
 Determination of Eligibility and Enrollment
 Sample ID Cards
• Verifying Eligibility
• PCP Role in Determining Eligibility
• Member Rights and Responsibilities
1. 2 West Virginia Family Health Benefits
• Medicaid Cost-Sharing
• Mountain Health Trust Benefits Table
• Mountain Health Bridge Benefits Table
• Copay Prohibition
• Dental Services
1.3 Growing Up Program
• General Information
 Service Delivery Requirements
 Growing Up Outreach Unit
 Claim Filing
 Authorization
• West Virginia Birth to Three
• Required Screens and Tests
• Detail of Screens and Services
 Dental Services and Screening: Child Under Age 21
 Orthodontic Requirement & Prior Authorization: Child Under Age 21
 Dental Services: Adult Age 21 and Over
 Dental Services Requiring Prior Authorization
 Dental Service Retrospective Review
 Dental Services in Hospital Setting or Ambulatory Surgical Center
 Vision Testing
 Hearing Screening
 Developmental/Behavioral Appraisal
 Anemia Screening
 Blood Lead Level Screening
 Immunizations
 Vaccines for Children (VFC) Program
 Immunization Registry
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CHAPTER 2 PROVIDER RESPONSILITIES
2.1 PCP’s Role
• General Information
 PCP Patient Panel
 Prospective Care Management
 Addition of Newborns
 Processing PCP Change Requests
 Transfer of Medical Records
• Appointment Standards
• Immunizations
 Vaccines For Children (VFC) Program
 Immunization Registry
• Oral Health Risk Assessment
• Transfer of Non-Compliant Members
• Coordination of Behavioral Health and Physical Health Services
2.2 Specialty Care Practitioner
• Verifying Eligibility
• Referrals Required for Specialty Care
• Appointment Standards
• Reimbursement
• Emergency Services
• Specialists Functioning as Primary Care Practitioners
2.3 OB/GYN Services
• General Information
 Member Self-Referral to OB/GYN
 PCPs & Routine Gynecological Services
 Referrals to Specialty Care Practitioners
 Diagnostic Testing
 Maternity Authorization
 Newborns
• Appointment Standards
• Prenatal Risk Screening Instrument (PRSI)
• Coding Maternity-Related Services
• Family Planning Guidelines and Billing
• Medicaid Sterilization/Hysterectomy Consent Forms
• Abortion Services
2.4 Hospital Services
• Inpatient Admissions
• Hospital Transfer Policy
• Outpatient Surgery Procedures
• Emergency Room
• Ambulance Services
• Billing and Reimbursement
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CHAPTER 3 POLICIES AND PROCEDURES
3.1 Practitioner Requirements and Guidelines
• General Information
 West Virginia DHHR/BMS Policy Changes
 Provider Manuals
 Practitioner Education and Sanctioning
 Practitioner Due Process
 Title VI of the Civil Rights Act of 1964
 Access and Interpreters for Members with Disabilities
 Provider Termination
• Credentialing Practices
• Confidentiality
• Fraud and Abuse
• Environmental Assessment Standards
• Reporting of Required Reportable Diseases
• NCQA Compliance Requirements
• Marketing Policies and Practices
3.2 Claims and Billing Information
• Member Billing Policy
• Excluded Providers or Credible Allegation of Provider Fraud
• Claims Submission
• Timely Filing
• Prompt Pay
 Payment Time Frames
 BMS Reimbursement Hold Harmless
• Electronic Claims Submission
• Electronic Remittance Advance (ERA)
• Claims Review
 Administrative Claims Review
 Medical Claims Review
• Coordination of Benefits
 Coordination of Benefits Policy
 Specialty/Fee-For-Service Providers
 Medicare
 Nursing Care
 Subrogation
• Primary Care Services
• Claim Coding Software
• Billing
• Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)
Services
 EPSDT Claim Submission Time Frame
 FQHC/RHC Billing
 1500 Paper Format Requirements
 1500 EDI Format Requirements
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• Obstetrical Care Services
• Hospital Services
• UB-04 Data Elements for Claims Submission
• Sample UB-04 Claim Form
• 1500 Data Elements for Claims Submission
• Sample 1500 Claim Form
3.3 Reimbursement
• Introduction
• Facility Providers
• Physicians and Other Providers
• Rate Changes
• Directed Payments to Certain Qualified Providers
3.4 Member and Provider Disputes
• Provider Appeals
• Provider Disputes
• Member Grievance Process
 Informal Grievances
 Formal Grievances
 External Grievance Review
• Member Appeals
• Provider Initiated Member Grievances or Appeals
CHAPTER 4 HEALTH CARE MANAGEMENT
4.1 Referrals
• General Information
• Voice Activated Referral
• Paper Referrals
• Referrals for Specific Services
 Out-of-Plan Referrals
 Referrals for Second Opinions
 Referrals for Surgical Second Opinions
 Specialty Care Practitioners
 Renal Dialysis Services
 Audiology and Speech Therapy
• Self-Referral
4.2 Authorizations
• General Information
 Criteria Used for Assessing Medical Appropriateness
 Review/Determination of Medical Necessity
 Utilization Management Contact Information
• Services Requiring Authorization
• Requesting an Authorization
 Information Needed When Requesting an Authorization
 Decision Time Frame
 Expedited Authorization Requests
 Medical Necessity Criteria
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 Post-Service Requests
• Chiropractic Services
• Durable Medical Equipment
• Skilled Nursing Facility
• Physical/Occupational/Speech Therapy
• Rehabilitation Services
 Extended Care in a Non-Hospital Facility
 Cardiac and Pulmonary Rehabilitation Services
• Home Health Care
• Hospice Services
• Pharmacy Services
• Diabetic Services
• New Technology
4.3 Care Management
• Lifestyle Management Programs Overview
 Maternity Program
 Asthma Program
 Diabetes Program
 Cardiac Program
 Chronic Obstructive Pulmonary Disease (COPD) Program
• Special Needs Care Management
• Complex Care Management
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APPENDIX FORMS AND REFERENCE MATERIALS
• DIVA Quick Referral Entry Guide
• HealthCheck Health History Form 0-6 Years
• HealthCheck Health History Form 7-20 Years
• HealthCheck Program Periodicity Schedule
• Hysterectomy Acknowledgment Form
• Maternity Outcome Authorization Form
• Medicaid Drug Exception Form
• Member Outreach Form
• Physician Certification for Hysterectomy
• Physician Certification for Pregnancy Termination
• Prenatal Risk Screening Instrument (PRSI)
• Quick Reference Guide for Referrals and Authorization
• Referral Form
• Refund Form
• Sterilization Consent Form
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QUICK REFERENCE
CALL TO INQUIRE ABOUT:
TELEPHONE NUMBER
HOURS OF OPERATION
Behavioral Health
1-855-371-8112
Monday – Friday
8:30 a.m. to 4:30 p.m.
Care Management
1-855-412-8004
Monday – Friday
8:30 a.m. to 4:30 p.m.
Option 1: Maternity Program
Option 2: Care Management/
Disease Management –
Congestive Heart
Failure/Asthma/Diabetes
Option 3: Preventive Health
Services/EPSDT/Outreach
Option 4: Complex Care
Management
FAX NUMBER
General:
1-855-430-9846
Prenatal Risk Forms
& Member Outreach
Forms:
1-855-430-9847
1-262-721-0722
Dental Provider Services
1-855-434-9237
Monday – Friday
8:30 a.m. to 4:30 p.m.
(Central Time)
Digital Voice Assistant DIVA
1-888-907-8002
24 hours a day/
7 days a week
Fraud and Abuse and
Compliance Hotline
1-855-412-8004
24 hours a day/
7 days a week
1-855-412-8003
Monday – Friday
8:30 a.m. to 4:30 p.m.
1-855-430-9848
(Claims Inquiries and
Eligibility Verification)
(Eligibility Check/Generate
and Review Referrals)
Medical Management
(Utilization Management)
Please do not leave multiple
voicemail messages or call for
the same authorization request
on the same day.
(Voicemail during off
hours. The call will be
returned the next day.)
Member Services
1-855-412-8001
Monday – Friday
8 a.m. to 8 p.m.
1-855-430-9845
Pharmacy
1-855-412-8005
Monday – Friday
8:30 a.m. to 4:30 p.m.
1-855-430-9849
1-855-412-8002
Monday – Friday
8:30 a.m. to 4:30 p.m.
1-855-430-9850
(Non-Formulary Requests and
Prior Authorizations)
Provider Services
(Claims Inquiries and
Eligibility Verification)
TTY/TDD Line
711 or 1-800-982-8771
24-Hour Nurse Help Line
1-844-850-WVFH(9834)
24 hours a day/
7 days a week
Please Note: After regular business hours, the Provider Services department line will be answered by
an automated system that provides callers with operating hours information and instructions on how
to verify enrollment for a member with an Urgent Condition or an Emergency Medical Condition.
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MAILING ADDRESSES
West Virginia Family Health – Claims Department
P.O. Box 830499
Birmingham, AL 35283
Emdeon & RelayHealth Electronic Claims Submission Payer ID: 45276
West Virginia Family Health – Dental Claims Department
P.O. Box 1597
Milwaukee, WI 53201
West Virginia Family Health – Provider Correspondence
P.O. Box 22278
Pittsburgh, PA 15222
West Virginia Family Health – Member Correspondence
P.O. Box 22250
Pittsburgh, PA 15222
West Virginia Family Health – Dental Authorizations Department
P.O. Box 628
Milwaukee, WI 53201
West Virginia Family Health – Dental Provider Correspondence and Appeals
P.O. Box 1462
Milwaukee, WI 53201
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INTRODUCTION
Highmark Blue Cross Blue Shield West Virginia (“Highmark West Virginia”) has contracted a network
of providers to service the West Virginia Medicaid population for the West Virginia Family Health
Plan, Inc. (“WVFH”). WVFH is a Provider Sponsored Network (“PSN”) organization composed of 26
shareholders, including 22 Federally Qualified Health Centers (“FQHCs”), two clinics, the Primary Care
Association and Highmark West Virginia. WVFH is based in West Virginia and intends to operate as a
Managed Care Organization (“MCO”) providing services to Medicaid beneficiaries. Hereinafter, WVFH
may also be referred to as MCO.
The PSN model offers many benefits and gives WVFH the ability to have a stronger focus on quality of
care through care and disease management and address socio-economic issues as well as those
unique issues to the low income population. Combining the hands on experience of providers with
the industry expertise of Highmark West Virginia will ensure that this PSN will provide superior care.
WVFH and Highmark West Virginia intend to collaboratively participate in the West Virginia Medicaid
program to create a more effective care delivery system and improve the overall health of West
Virginia Medicaid recipients. This combined ownership integrates the strengths of the provider
community with a health insurance issuer that has a strong historical state-wide presence and
leverages the strengths of both to create a new Medicaid MCO.
This partnership provides an opportunity to create a healthcare delivery system designed to improve
access to and quality of care for West Virginians, as well as promote healthier outcomes through
medical home systems of care.
© 2016 Highmark Inc. All rights reserved.
Confidential Information – DO NOT DUPLICATE except for
West Virginia Medicaid managed care program review activities.
This manual is exempt from disclosure pursuant to WV Uniform Trade Secrets Act §47-22-1 et seq., and WV FOIA
§29B-1-4(a). Information in this document is not generally known to individuals outside WVFH and has commercial
value for WVFH’s competitive advantage. Unauthorized use or disclosure constitutes misappropriation of a Trade Secret
and harm to WVFH’s competitive position, addressed through criminal and/or civil penalties to the disclosing party.
Highmark Blue Cross Blue Shield West Virginia is an independent licensee of the Blue Cross and Blue Shield Association.
WEST VIRGINIA FAMILY HEALTH PROVIDER MANUAL | INTRODUCTION
FEBRUARY 2016
CHAPTER 1: MEMBER ENROLLMENT AND BENEFITS
UNIT 1: ENROLLMENT AND ELIGIBILITY
IN THIS UNIT
TOPIC
Enrollment Process
• Determination of Eligibility and Enrollment
• Sample ID Cards
Verifying Eligibility
PCP Role in Determining Eligibility
Member Rights and Responsibilities
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1.1 ENROLLMENT PROCESS
Determination
of eligibility
and
enrollment
Mountain Health Trust is the name for West Virginia’s Medicaid mandatory
managed care program for Temporary Assistance for Needy Families (TANF) and
TANF-related children and adults who are eligible to participate in managed care.
West Virginia Health Bridge (“WVHB”) is West Virginia’s mandatory managed care
program for adults eligible for the Medicaid Alternative Benefit Plan (ABP) under
Medicaid expansion through the Affordable Care Act (ACA).
Under the West Virginia Mountain Health Trust Program and WVHB, the State
determines eligibility, and enrollment is determined through Maximus, a broker
hired by the State of West Virginia for enrollment services.
Once the beneficiary selects West Virginia Family Health (“WVFH”), the plan is
notified electronically of enrollment. At that time, a packet of information is sent
along with their WVFH ID card.
Sample ID
cards
Mountain Health Trust
Front:
Back:
Mountain Health Bridge
Front:
Back:
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1.1 VERIFYING ELIGIBILITY
Overview
A West Virginia Family Health Member (WVFH) member will have two (2) cards:
The WVFH ID card, as well as the West Virginia Medicaid card. Because of frequent
changes in a member’s eligibility, each Network practitioner is responsible to
verify a member’s eligibility with WVFH BEFORE providing services. Verifying a
member’s eligibility along with the applicable referral or authorization will assure
proper reimbursement for services.
Methods of
verifying
a member’s
eligibility
To verify a member’s eligibility, the following methods are available to all
practitioners:
1. WVFH Identification Card
The card itself does NOT guarantee that a person is currently enrolled in
WVFH. Members are only issued an ID card once upon enrollment, unless
the member changes their Primary Care Practitioner (PCP) or requests a
new card. Members are NOT required to return their identification cards
when they are no longer eligible for WVFH.
2. The WVFH Interactive Voice Response System (IVR) System
Available 24 hours a day, seven days a week at 1-888-907-8002.
To verify member eligibility at each visit, practitioners follow a few simple
steps which are listed below.
Verifying
eligibility via
the WVFH IVR
System
The WVFH IVR System can be accessed by calling 1-888-907-8002.
• Press 1 to verify eligibility
• MEMBER IDENTIFICATION NUMBER QUESTION:
 Press 1 to verify eligibility using the patient’s social security number.
When prompted enter the patient’s 9-digit social security number,
and then press the # key.
 Press 2 to verify eligibility using the patient’s WVFH member
identification number. When prompted, enter the patient’s 8-digit
WVFH identification number.
 Press 3 to verify eligibility using the patient’s West Virginia Medicaid
recipient identification number. When prompted, enter the patient’s
West Virginia Medicaid recipient identification number.
 Press 0 to speak to a Provider Services Representative.
 Press 9 to repeat the menu.
Continued on next page
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1.1 VERIFYING ELIGIBILITY, Continued
Verifying
eligibility via
the WVFH IVR
System
(continued)
• VERIFICATION OF DATE QUESTION:
 Press 1 to verify whether the patient is eligible TODAY or the PCP
assigned to the member TODAY.
 Press 2 to verify whether the patient is eligible on a specific date.
Enter the date using the 2-digit month, 2-digit day, and 4-digit year.
o Press 1 if the repeated date is correct.
o Press 2 if the repeated date is incorrect.
o Press 9 to listen to the instructions again.
 Press 0 to speak to a Provider Services Representative.
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1.1 PCP ROLE IN DETERMINING ELIGIBILITY
Practitioner
panel list
Primary care practitioners (PCPs) can verify eligibility by consulting their panel
listing in order to confirm that the member is a part of the practitioner’s panel. The
panel list is distributed on or about the first of every month.
The primary care practitioner should check the panel list each time a member is
seen in the office. If a member’s name is on the panel list, the member is eligible
with WVFH for that month.
If a patient is
not on the
practitioner’s
panel list
If patients insist they are effective, but do not appear on the practitioner’s panel
list, the practitioner should call the WVFH Provider Services Department at
1-855-412-8002 for help in determining eligibility.
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1.1 MEMBER RIGHTS AND RESPONSIBILITIES
Introduction
Member
Rights
As members of West Virginia Family Health (WVFH), patients have the following
rights and responsibilities.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
Learn about their rights and responsibilities.
Get the help they need to understand their member handbook.
Learn about WVFH, its services, doctors, and other health care providers.
See their medical records as allowed by law.
Have their medical records kept private unless they tell WVFH in writing that
it is okay for WVFH to share them or it is allowed by law.
Be part of honest talks about their health care needs and treatment options
no matter the cost and whether their benefits cover them. Be part of
decisions that are made by their doctors and other providers about their
health care needs.
Be told about other treatment choices or plans for care in a way that fits their
condition.
Get news about how doctors are paid.
Find out how WVFH decides if new technology or treatment should be part
of a benefit.
Be treated with respect, dignity, and the right to privacy all the time.
Know that WVFH, their doctors, and their other health care providers cannot
treat them in a different way because of their age, sex, race, national origin,
language needs, or degree of illness or health condition.
Talk to their doctor about private things.
Have problems taken care of fast, including things they think are wrong, as
well as issues about their coverage, getting an approval from WVFH, or
payment of service.
Be treated the same as others.
Get care that should be done for medical reasons.
Be free from any form of restraint or seclusion used as a means of coercion,
discipline, convenience, or retaliation.
Choose their PCP from the PCPs in WVFH’s Provider Directory that are taking
new patients.
Use providers who are in WVFH’s networks.
Get medical care in a timely manner.
Get services from providers outside WVFH’s network in an emergency.
Refuse care from their PCP or other caregivers.
Be able to make choices about their health care.
Make an Advance Directive (also called a Living Will).
Continued on next page
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1.1 MEMBER RIGHTS AND RESPONSIBILITIES, Continued
Member
Rights
(continued)
24. Tell WVFH their concerns about WVFH and the health care services they get.
25. Question a decision WVFH makes about coverage for care they got from
their doctor.
26. File a complaint or an appeal about WVFH, any care they get, or if their
language needs are not met.
27. Ask how many grievances and appeals have been filed and why.
28. Tell WVFH what they think about their rights and responsibilities and
suggest changes.
29. Ask WVFH about its Quality Improvement Program and tell WVFH how they
would like to see changes made.
30. Ask WVFH about its utilization review process and give us ideas on how to
change it.
31. Know the date WVFH uses when they joined our health plan decides their
benefits.
32. Know that WVFH only covers health care services that are part of their plan.
33. Know that WVFH can make changes to their health plan benefits as long as
WVFH tells them about those changes in writing.
34. Ask for an Evidence of Coverage and other member materials in other
formats such as large print, audio CD, or Braille at no charge to them.
35. Ask for an oral interpreter and translation services at no cost to them.
36. Use interpreters who are not their family members or friends.
37. Know they are not liable if their health plan becomes bankrupt (insolvent).
38. Know their provider can challenge the denial of service with their approval.
Member
Responsibilities
To receive the best care, members must do their part.
1. Tell WVFH, their doctors, and other health care providers what they need to
know to treat them.
2. Learn as much as they can about their health issue and work with their
doctor to set up treatment goals they agree on with their doctor.
3. Ask questions about any medical issue and make sure they understand
what their doctor tells them.
4. Follow the care plan and instructions that they have agreed on with their
doctors or other health care professionals.
5. Do the things that keep them from getting sick.
6. Make and keep medical appointments and tell their doctor at least 24 hours
in advance when they cannot make it.
7. Always show their Member ID card when they get health care services.
Continued on next page
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1.1 MEMBER RIGHTS AND RESPONSIBILITIES, Continued
Member
Responsibilities
(continued)
8. Use the emergency room only in cases of an emergency or as their doctor
tells them.
9. If they owe a copay to their hospital, PCPs, or pharmacies, pay at the time
the services are received.
10. Tell WVFH right away if they get a bill they should not have gotten or if they
have a complaint.
11. Treat all WVFH staff and doctors with respect and courtesy.
12. Know and follow the rules of their health plan.
13. Know that laws guide their health plan and the services they get.
14. Know that WVFH does not take the place of workers’ compensation
insurance.
15. Tell their DHHR caseworker and WVFH when they change their address,
family status, or other health care coverage.
If a minor becomes emancipated (over the age of sixteen) or marries, he or
she shall be responsible for following all WVFH member guidelines set forth
above.
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CHAPTER 1: MEMBER ENROLLMENT AND BENEFITS
UNIT 2: WEST VIRGINIA FAMILY HEALTH BENEFITS
IN THIS UNIT
TOPIC
Medicaid Cost-Sharing
Mountain Health Trust Benefits Table
Mountain Health Bridge Benefits Table
Copay Prohibition
Dental Services
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1.2 MEDICAID COST-SHARING
Overview
Medicaid members will be required to pay for a portion of their care based on the
member’s family income. The Bureau of Medical Services (BMS) determines these
copay amounts, and there are no premiums, deductibles, or other cost-sharing
obligations for the member under the West Virginia Medicaid program.
SERVICE
Up to 50.0% FPL1
50.01 – 100.00% FPL1
Inpatient Hospital
Office Visit (Physicians & Nurse Practitioner)
Prescription Drugs2
Non-Emergency Use of Emergency
Department – Hospital Only
Any services received during a visit coded
as non-emergent surgical procedures
provided in a physician’s office, ambulatory
surgical center, or any other outpatient
setting excluding emergency rooms.
$0
$0
$35
$2
100.01% FPL1
and above
$75
$4
$8
$8
$8
$0
$2
$4
1
2
Federal Poverty Level
Copays on all Medicaid prescription drugs are listed below.
Medicaid
prescription
drug copays
Copays
prohibited
TOTAL ALLOWED CHARGE
CO-PAYMENT
$0.00 - $5.00
$5.01 - $10.00
$10.01 - $25.00
$25.01 - $50.00
$50.01 and above
$0.00
$0.50
$1.00
$2.00
$3.00
WVFH will not charge copays per BMS requirements for:
•
•
•
•
•
•
•
Children under age 21
Pregnant women, including the 60 day period after the pregnancy ends
American Indians and Alaska Natives
Members receiving hospice care in a nursing home
Dental services
Emergency room services (for emergent use of hospital ER only)
72 Hour emergency supply of medication
Continued on next page
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1.2 MEDICAID COST-SHARING, Continued
No copays
per BMS
requirements
(continued)
•
•
•
•
•
Family planning services
Diabetic testing supplies, syringes, and needles from a pharmacy ONLY
BMS approved home infusion supplies
Members in a nursing home
Members who meet household maximum limit for cost sharing
obligations per calendar quarter
• Other limits may apply as provided by the state plan amendment
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1.2 MOUNTAIN HEALTH TRUST BENEFITS TABLE
CHILDREN (0 up to 21 years)
ADULTS (21 years and older)
Inpatient Services (Note A, B, C, and D below)
• Inpatient Hospital Care
• Inpatient Rehabilitation
Inpatient Services (Note A, B, C, and D below)
• Inpatient Hospital Care
Outpatient Services
• Diagnostic X-ray, laboratory services, and
testing
• Physical Therapy
• Speech Therapy
• Occupational Therapy
• Ambulatory Surgery Center Services
• Clinic Services
Outpatient Services
• Diagnostic X-ray, laboratory services, and
testing
• Physical Therapy
• Speech Therapy
• Occupational Therapy
• Ambulatory Surgery Center Services
• Clinic Services
Physician/NP/NMW/FQHC/RHC Services
• Primary/Preventive Care Visits
• Physician Office Visits
• Specialty Care
• Podiatry
Physician/NP/NMW/FQHC/RHC Services
• Primary/Preventive Care Visits
• Physician Office Visits
• Specialty Care
• Podiatry
Cardiac and Pulmonary Rehabilitation
Cardiac and Pulmonary Rehabilitation
Dental (General dentistry)
Refer to page 56 in Scion Dental Provider Manual
Dental Services (Emergent treatment only)
Home Health
Home Health
Durable Medical Equipment
• Orthotics & Prosthetics
Durable Medical Equipment
• Orthotics & Prosthetics
Family Planning Services & Supplies
Family Planning Services & Supplies
Hospice (In-home care)
Hospice (In-home care)
Ambulance (Emergency transportation)
Ambulance (Emergency transportation)
Prescriptions
Prescriptions
Chiropractic Services
Chiropractic Services
Tobacco Cessation
Tobacco Cessation
Diabetes Management
Diabetes Management
Private Duty Nursing
Vision
Vision benefits are limited to medical treatment
only
Hearing
EPSDT (Well-child visits)
Continued on next page
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1.2 MOUNTAIN HEALTH TRUST BENEFITS TABLE, Continued
CHILDREN (0 up to 21 years)
Behavioral Health Services
• Inpatient Psychiatric and Behavioral Health
Stay
• Inpatient Chemical Dependency/Mental
Health Stay
• Outpatient and Psychological Services
• Rehabilitation in Residential Treatment
• Inpatient Psychiatric Services
ADULTS (21 years and older)
Behavioral Health Services
• Inpatient Psychiatric and Behavioral Health
Stay
• Inpatient Chemical Dependency/Mental
Health Stay
• Outpatient and Psychological Services
The services below are covered through Medicaid, but are not provided through your plan. For
information, on how to use these services, look at section of the handbook that explains what
Medicaid covers.
Nursing Home Services
Nursing Home Services
Non-Emergency Transportation
Non-Emergency Transportation
(A) If the member is participating in a chronic care health home, the health home must be notified
of any use of emergency services. They will be notified of any inpatient admission or discharge
of a health home member that WVFH learns of through its inpatient admission initial
authorization and concurrent review processes within 24 hours.
(B) If the member is in an inpatient facility on the date of their enrollment with WVFH, the inpatient
charges and the charges for a transfer facility will be paid by BMS. This includes charges billed
while they are in the hospital, transferred to another hospital during their illness, or transferred
inside the same hospital. WVFH will be responsible for all other covered services on or after the
effective date. These charges include:
a. Emergency transportation
b. Doctor and other professional fees while you are at the hospital
c. Outpatient care
(C) WVFH is responsible for all charges during the inpatient newborn stay if newborn is born to a
mother who is a current WVFH member until the newborn is discharged from the hospital.
(D) WVFH is not responsible for inpatient charges for a member who is no longer eligible for
Medicaid coverage as of the first of the month following the loss of Medicaid coverage.
Nursing home services: The services are covered through Medicaid fee-for-service.
Non-emergency transportation: MTM is available to provide non-emergency medical transport
needs. MTM will schedule the request for transportation and send a ride to the member. MTM’s Call
Center is available Monday-Friday, 7 a.m. to 6 p.m., by calling 1-844-549-8353 for a
reservation. If the member needs to follow up on a previously scheduled appointment, they can call
the Where’s My Ride hotline at 1-844-549-8354 (TTY 1-800-855-2880).
Continued on next page
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1.2 MOUNTAIN HEALTH TRUST BENEFITS TABLE, Continued
Chemical dependency/behavioral health services: Members do not need a referral for behavioral
health services, including behavioral health care (depression) or drug and alcohol abuse.
Birth to Three services: To be eligible for Birth to Three services, an infant or toddler under the age
of three can either have a delay in one or more areas of their development, or be at risk of possibly
having delays in the future. If you are interested in referring your child for services or would like more
information, in West Virginia call 1-800-642-8522 or visit the Birth to Three website at
http://www.wvdhhr.org/birth23/.
Nursing Facility Services: Facility-based nursing services to those who require 24 hour nursing care
are not covered.
Vision: In addition to the BMS benefits covered by WVFH, all adult members are eligible for one
routine eye exam and one pair of eyeglasses annually as a benefit from WVFH. Additionally, contact
lenses are provided for the diagnosis of aphakia or keratoconus with prior approval.
Weight management services are not a covered benefit except for bariatric surgery which is a
covered benefit under the fee-for-service.
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1.2 MOUNTAIN HEALTH BRIDGE BENEFITS TABLE
CHILDREN (0 up to 21 years)
ADULTS (21 years and older)
Inpatient Services (Note A,B, C and D below)
• Inpatient Hospital Care
• Inpatient Rehabilitation
Inpatient Services (Note A,B, C and D below)
• Inpatient Hospital Care
Outpatient Services
• Diagnostic X-ray, laboratory services, and
testing
• Physical Therapy
• Speech Therapy
• Occupational Therapy
• Ambulatory Surgery Center Services
• Clinic Services
Outpatient Services
• Diagnostic X-ray, laboratory services, and
testing
• Physical Therapy
• Speech Therapy
• Occupational Therapy
• Ambulatory Surgery Center Services
• Clinic Services
Physician/NP/NMW/FQHC/RHC Services
• Primary/Preventive Care Visits
• Physician Office Visits
• Specialty Care
• Podiatry
Physician/NP/NMW/FQHC/RHC Services
• Primary/Preventive Care Visits
• Physician Office Visits
• Specialty Care
• Podiatry
Cardiac and Pulmonary Rehabilitation
Cardiac and Pulmonary Rehabilitation
Dental
• Orthodontics
Dental Services (Emergent Treatment)
Home Health
Home Health
Durable Medical Equipment
• Orthotics & Prosthetics
Durable Medical Equipment
• Orthotics & Prosthetics
Family Planning Services & Supplies
Family Planning Services & Supplies
Hospice (In-home care)
Hospice (In-home care)
Ambulance (Emergency transportation)
Ambulance (Emergency transportation)
Prescriptions
Prescriptions
Chiropractic Services
Chiropractic Services
Tobacco Cessation
Tobacco Cessation
Diabetes Management
Diabetes Management
Private Duty Nursing
Vision
Vision – See below
Hearing
Continued on next page
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1.2 MOUNTAIN HEALTH BRIDGE BENEFITS TABLE, Continued
CHILDREN (0 up to 21 years)
Behavioral Health Services
• Inpatient Psychiatric and Behavioral Health
Stay
• Inpatient Chemical Dependency/Mental
Health Stay
• Outpatient and Psychological Services
• Rehabilitation in Residential Treatment
ADULTS (21 years and older)
Behavioral Health Services
• Inpatient Psychiatric and Behavioral Health
Stay
• Inpatient Chemical Dependency/Mental
Health Stay
• Outpatient and Psychological Services
The services below are covered through Medicaid, but are not provided through your plan. For
information on how to use these services, look at the section of the handbook that explains what
Medicaid covers.
Nursing Home Services
Nursing Home Services
Non-Emergency Transportation
Non-Emergency Transportation
(A) If the member is participating in a chronic care health home, the health home must be
notified of any use of emergency services. They will be notified of any inpatient admission or
discharge of a health home member that WVFH learns of through its inpatient admission
initial authorization and concurrent review processes within 24 hours.
(B) If the member is in an inpatient facility on the date of their enrollment with WVFH, the
inpatient charges and the charges for a transfer facility will be paid by BMS. This includes
charges billed while they are in the hospital, transferred to another hospital during their
illness, or transferred inside the same hospital. WVFH will be responsible for all other covered
services on or after the effective date. These charges include:
a. Emergency transportation
b. Doctor and other professional fees while you are at the hospital
c. Outpatient care
(C) WVFH is responsible for all charges during the inpatient newborn stay if newborn is born to a
mother who is a current WVFH member until the newborn is discharged from the hospital.
(D) WVFH is not responsible for inpatient charges for a member who is no longer eligible for
Medicaid coverage as of the first of the month following the loss of Medicaid coverage.
Nursing home services: The services are covered through Medicaid fee-for-service.
Non-emergency transportation: MTM is available to provide non-emergency medical transport
needs. MTM will schedule the request for transportation and send a ride to the member. MTM’s Call
Center is available Monday-Friday, 7 a.m. to 6 p.m., by calling 1-844-549-8353 for a
reservation. If the member needs to follow up on a previously scheduled appointment, they can call
the Where’s My Ride hotline at 1-844-549-8354 (TTY 1-800-855-2880).
Continued on next page
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1.2 MOUNTAIN HEALTH BRIDGE BENEFITS TABLE, Continued
Vision: In addition to the BMS services covered by WVFH, all adult members are eligible for one
routine eye exam and one pair of eyeglasses annually as a benefit from WVFH, and contact lenses for
the diagnosis of aphakia or keratoconus with prior approval, annually.
Chemical dependency/behavioral health services: Members do not need a referral for behavioral
health services, including behavioral health care (depression) or drug and alcohol abuse.
Nursing Facility Services: Facility-based nursing services to those who require 24 hour nursing care
are not covered.
In addition to the BMS benefits covered by WVFH, all adult members are eligible for one routine eye
exam, one pair of eyeglasses within 60 days of cataract surgery, and contact lenses for the diagnosis
of aphakia or keratoconus with prior approval, annually.
Weight management services are not a covered benefit except for bariatric surgery which is a
covered benefit under the fee-for-service.
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1.2 COPAY PROHIBITION
Copays
prohibited
Providers may not charge copays to the following members or on the following
services:
• Family planning services;
• Emergency services;
• 72-hour emergency supply of medication;
• Following pharmacy services: diabetic testing supplies, syringes, and
needles; and home infusion supplies approved by BMS;
• Members under age 21;
• Pregnant women (including the 60-day postpartum period following the
end of pregnancy);
• American Indians and Alaska Natives;
• Members receiving hospice care;
• Members in nursing homes;
• Any additional members or services excluded under the State Plan
authority1; or
 Dental services
 Emergency room services (for emergent use of hospital ER only)
 PDL drugs
• Members who have met their annual maximum limit for the cost-sharing
obligations:
 Maximum limit based on five percent (5%) of quarterly household
income:
o January – June 2014 Medical only copays
o July – December 2014 medical and pharmacy copays
 Other limits may apply.
Services excluded under State Plan authority currently include Dental Services,
Emergency Services, Family Planning, PDL drugs, and services for provider-preventable
conditions are excluded from the copays requirement. Members with the federal poverty
level (FPL) under 50 percent (50%) are exempt from inpatient and professional office visit
copays.
1
Copays
allowed
Providers may charge copays for the following services:
• Inpatient and Outpatient services;
• Pharmacy medications;
• Non-emergency use of the Emergency Department;
• Physician office visits including but not limited to a psychiatrist or a nurse
practitioner;
• Caretaker relatives age 21 and up;
• Transitional Medicaid members age 21 and up; and
• Any other members identified by WVFH who are not specifically exempt.
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1.2 DENTAL SERVICES
Dental services
in partnership
with Scion
Dental
WVFH permits members to have access to dental providers in the Scion Dental
network. Our partnership is designed to deliver the highest quality oral health
solutions to plan members.
To locate a provider for your patient, please see the network provider listing
through the website: http://sciondental.com/sd/Members/Find-A-Dentist.htm.
Members should be advised to refer to their Member Handbook for additional
information related to dental benefits, authorizations, and referrals related to
dental services.
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CHAPTER 1: MEMBER ENROLLMENT AND BENEFITS
UNIT 3: GROWING UP PROGRAM
IN THIS UNIT
TOPIC
SEE PAGE
General Information
• Service Delivery Requirements
• Growing Up Outreach Unit
• Claim Filing
• Authorization
West Virginia Birth to Three
Required Screens and Tests
Detail of Screens and Services
• Dental Services and Screening: Child Under Age 21
• Orthodontic Requirement & Prior Authorization: Child
Under Age 21
• Dental Services: Adult Age 21 and Over
• Dental Services Requiring Prior Authorization
• Dental Service Retrospective Review
• Dental Services in Hospital Setting or Ambulatory
Surgical Center
• Vision Testing
• Hearing Screening
• Developmental/Behavioral Appraisal
• Anemia Screening
• Blood Lead Level Screening
• Immunizations
• Vaccines for Children (VFC) Program
• Immunization Registry
2
2
3
3
3
4
5
7
7
7
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8
9
10
10
11
11
12
13
13
15
16
16
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1.3 GENERAL INFORMATION
EPSDT
overview
West Virginia Family Health’s (WVFH’s) Growing Up Program is based upon the
federally mandated Early and Periodic Screening, Diagnosis, and Treatment
(EPSDT) Program for Medical Assistance eligible children under the age of 21
years. Through the EPSDT Program, children are eligible to receive regular
medical, dental, vision, and hearing screens to assure that they receive all
medically necessary services, without regard to Medical Assistance covered
services.
Each Network PCP and primary care/specialist is responsible for providing the
health screens for WVFH members, and reporting the results of the screens to
WVFH, as well as communicating demographic information (e.g. telephone
number, address, alternate address) with the WVFH Outreach staff to assist with
scheduling, locating and addressing compliance issues.
PCPs that treat children under the age of 21 that are unable to comply with the
requirements of the EPSDT Program must make arrangements for EPSDT screens
to be performed elsewhere by a WVFH Network provider. Alternative PCPs and
specialists should forward a copy of the completed progress report to the PCP so
it can be placed in the member’s chart.
Service
delivery
requirements
PCPs are required to assure all children under the age of 21 have timely access to
EPSDT services, and are responsible for assuring continued coordination of care
for all members due to receive EPSDT services. Also, PCPs are to arrange for
medically necessary follow-up care after a screen or an encounter.
The required screens and tests are outlined later in this section. PCPs are required
to follow this schedule to determine when the necessary screens and tests are to
be performed. Members must receive, at a minimum, eight screens between the
ages of birth and 18 months, and seventeen screens between 19 months and 21
years.
When treating Supplemental Security Income (“SSI”) and SSI-related members
under the age of 21, an initial assessment must be conducted at the first
appointment. Written assessment must be discussed with the member’s family or
custodial agency, grievance or appeal rights must be presented by the PCP, and
recommendations regarding case management must be documented.
PCPs are responsible for ongoing coordination and monitoring of care provided
by other practitioners.
Continued on next page
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1.3 GENERAL INFORMATION, Continued
Growing Up
Outreach Unit
WVFH’s Growing Up Outreach Unit works collaboratively with the Care Managers
in coordinating medically necessary services to members. Staff provides outreach
via telephone, mail, or home visitation when required, to members who are under
21 to provide education and assistance with scheduling appointments,
transportation, and other issues that prevent access to health care. WVFH
Outreach staff is available to outreach to members identified by the primary care
practitioner (PCP) offices who are delayed with screens and/or immunizations or
who are non-adherent with appointments.
The PCP is responsible for contacting new members identified on encounter lists
as not adhering to EPSDT periodicity and immunization schedules. The Growing
Up contact person is an EPSDT Outreach Representative who can be reached at
1-855-412-8004, Option 3.
Please complete and mail to WVFH the Member Outreach Form, also located in
this manual’s Appendix, for any member with abnormal findings, or who did not
show up for his/her appointment, so WVFH may contact the member.
Claim
filing
WVFH requires all EPSDT screens be billed on a 1500 or UB-04, or successor form.
Codes for services must be included on the form. A description of the services will
not be accepted. The practitioner’s tax identification number must be included on
the form to avoid problems with payment of services. WVFH does not apply
coordination of benefits to EPSDT screens. Completed paper claim forms should
be submitted within sixty (60) days of the date of service to permit timely member
outreach. Claims will be accepted up to 365 days following the date of service;
however, missing EPSDT screening claims cause unnecessary outreach to
members and providers.
Please refer to the manual’s Chapter 3, Unit 2: Claims and Billing for additional
information regarding submission of claims for EPSDT visits.
Authorization
If a member needs to be referred for specialty care as a result of an EPSDT
screening, a standard WVFH referral must be issued by the primary care
practitioner (PCP) to an applicable specialist.
Hospital admissions and some outpatient surgical procedures require
authorization from the Utilization Management Department.
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1.3 WEST VIRGINIA BIRTH TO THREE
Overview
Following an EPSDT screen, if a developmental delay is suspected and the child is
not receiving services at the time of the screening, the PCP may refer the child
(not over three years of age) to West Virginia Birth to Three.
What is WV
Birth to Three?
West Virginia Birth to Three is a statewide system of services and supports for
children under age three who have a delay in their development, or may be at risk
of having a delay, and their family.
The Department of Health and Human Resources, through the Bureau for Public
Health and the Office of Maternal, Child and Family Health, WV Birth to Three, as
the lead agency for Part C of the Individuals with Disabilities Education Act (IDEA),
assures that family-centered community-based services are available to all eligible
children and families.
To refer a child to the West Virginia Birth to Three system in-state, you may call
1-866-321-4728.
FOR MORE
INFORMATION
For more information regarding WV Birth to Three, visit their website at
http://www.wvdhhr.org/birth23/.
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1.3 REQUIRED SCREENS AND TESTS
HealthCheck
Program
Periodicity
Schedule
The required screens and testing are listed below. Refer to the HealthCheck
Program Periodicity Schedule on the next page for frequency of testing and for
further clarification.
Individuals
birth
through
3 years
1. Record of a health history from parent or guardian.
2. Unclothed physical examination
3. Developmental appraisal (Denver Test or equivalent), psychosocial and
behavioral assessment
4. Autism screening
5. Growth measurement
6. Assessment of hearing and vision
7. Metabolic screening – PKU
8. Anemia screening – hemoglobin and/or hematocrit
9. Blood lead screening
10. Urine screen for bacteria, sugar, albumin (age 2-6)
11. Sickle Cell test
12. Tuberculosis testing
13. Evaluation for cholesterol screening
14. Assessing and updating appropriate immunizations
15. Oral health screening
16. Nutritional assessment
Note: The claim forms do not indicate findings from the clinical exam. It is the
responsibility of the PCP to document these findings in the medical record.
The initial EPSDT screen shall be the newborn physical examination in the hospital
provided that the newborn physical examination contains all of the EPSDT
screening components.
Individuals
3 years
through
age 20
1.
2.
3.
4.
5.
6.
7.
8.
Record of a health history from parent or guardian
Unclothed physical examination, including Tanner score and blood pressure
Developmental, psychosocial, and behavioral appraisal
Vision test
Hearing test
Dental examination
Malnutrition evaluation
Tuberculosis testing
Continued on next page
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1.3 REQUIRED SCREENS AND TESTS, Continued
Individuals
3 years
through
age 20
(continued)
FOR MORE
INFORMATION
9.
10.
11.
12.
13.
14.
15.
Iron anemia-hemoglobin and hematocrit
Lead poisoning evaluation (mandatory until age 6)
Sickle Cell testing
Evaluation for cholesterol screening
Assessing and updating appropriate immunizations
Nutritional assessment
STD screening and pap smear
For more information regarding the HealthCheck Program, visit the website at
www.wvdhhr.org/healthcheck.
HealthCheck Program
Periodicity Schedule
Click here for a larger printable version. The larger version is also available
in the Appendix of this manual.
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1.3 DETAIL OF SCREENS AND SERVICES
Dental Services
and Screening:
Child under
age 21
A dental assessment at every well-child visit, through observation, should be
conducted. A referral to a dentist is required beginning at 6 months after the first
tooth erupts or by 12 months of age. The child should see the dentist every six
months. The dentist must check for the following and initiate treatment or refer as
necessary:
• Caries
• Fillings Present
• Missing Teeth (permanent)
• Oral Infection
Dental services include relief of pain and infections, restoration of teeth and
maintenance of dental health. Although an oral health screening is a part of a
well-child exam, it does not substitute for referral to and examination by a dentist.
Remember: West Virginia Medicaid covers all children's dental services (up to age
21) for cleanings and fillings without a referral.
Orthodontic
requirement &
prior
authorization:
Child under
age 21
WVFH has specific dental utilization criteria as well as a prior authorization to
manage the utilization of services. Consequently, WVFH’s operational focus is on
assuring compliance with its dental utilization criteria.
The contact phone number for Dental Provider Services (Claims Inquiries and
Eligibility Verification) is 1-855-434-9237.
Orthodontic documentation requirements include, but are not limited to:
• A treatment plan (Orthodontics)
• Six (6) diagnostic quality photos
• Panoramic or FMX X-ray
• Cephalometric X-ray
• Prior authorization request
• WV Medicaid Orthodontic Prior Authorization Form
Please review the West Virginia Medicaid Clinical Criteria for Prior Authorization of
Treatment section that outlines of the clinical criteria for orthodontics.
Claims, dental/orthodontic authorization requests and supporting documents, and
provider correspondence and appeals can be submitted to the following addresses:
CLAIMS
AUTHORIZATIONS
CORRESPONDENCE & APPEALS
West Virginia Family Health
Dental Claims Department
P.O. Box 1597
Milwaukee, WI 53201
West Virginia Family Health
Dental Authorizations Department
P.O. Box 628
Milwaukee, WI 53201
West Virginia Family Health
Dental Provider Correspondence & Appeals
P.O. Box 1462
Milwaukee, WI 53201
Continued on next page
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1.3 DETAIL OF SCREENS AND SERVICES, Continued
Dental
services:
Adult age 21
and over
The covered adult (age 21 and over) dental benefit is for urgent/emergent
dental extractions. A referral from the PCP is not required for the initial
evaluation by the dental provider. The dental provider needs preauthorization
only if more than two (2) teeth are extracted or if IV sedation is requested. Panorex
films will be requested for extraction of more than two (2) teeth.
Examples of urgent/emergent dental services are:
• Dental caries with abscess
• Incision & Drainage (I&D) of abscess
• Repair of acute wounds
• Tooth broken off to the gum line
• Dental caries with pain
• Non-restorable tooth
Non- Covered Services
Dental services not covered by WVFH include, but are not limited to, the
following. Non-covered services are not eligible for Department of Health and
Human Resources hearing or desk/document review, and include:
• Experimental/investigational or services for research purposes
• Removal of primary teeth whose exfoliation is imminent
• Dental services for which PA has been denied or not obtained
• Dental services for the convenience of the member, the member’s
caretaker, or the provider of service
• Procedures for cosmetic purposes
• Temporomandibular Joint (TMJ) for adults
• Anesthesia services when solely for the convenience of the member, the
member’s caretaker, or the provider of service
• Local anesthesia and oral sedation are considered part of the treatment
procedures and may not be billed separately
• Dental services for residents of Intermediate Care and Nursing Facilities i.e.,
Nursing Home, ICF/MR, and PRTF
• Dental services for participants enrolled in the Division of Rehabilitation
Services or when services are covered under a Workers Compensation plan
• Dental services provided by providers not enrolled with WVFH
• Use of an unlisted code when a national CDT code is available
• Unbundled CDT codes
Note: The extraction of impacted wisdom teeth is not a covered benefit, but
wisdom teeth that are abscessed could meet the urgent/emergent guidelines.
The claim must document that the services were urgent/emergent.
Continued on next page
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1.3 DETAIL OF SCREENS AND SERVICES, Continued
Dental services
requiring prior
authorization
A decision will be made on a request for prior authorization within fourteen (14)
calendar days from the date the request is received. If the request is denied for
some or all of the services requested, the member and provider will be sent a
written notice of the reasons for the denial(s) and the member will be advised that
he or she may appeal the decision.
WVFH has specific dental utilization criteria as well as a prior authorization and
retrospective review process to manage the utilization of services. Consequently,
the operational focus is on assuring compliance with its dental utilization criteria.
One method used on a limited basis to assure compliance is to require providers
to supply specified documentation prior to authorizing payment for certain
procedures. Services that require prior authorization should not be started prior to
the determination of coverage (approval or denial of the prior authorization) for
non-emergency services. Non-emergency treatment started prior to the
determination of coverage will be performed at the financial risk of the dental
office. If coverage is denied, the treating dentist will be financially responsible and
may not balance bill the Member, the State of West Virginia, and or any agents,
and/or WVFH.
Prior authorizations will be honored for 180 days from the date they are issued. An
approval does not guarantee payment. The Member must be eligible at the time
the services are provided. The provider should verify eligibility at the time of
service.
Requests for prior authorization should be sent with the appropriate
documentation on an approved form. Any claims or Prior Authorizations
submitted without the required documentation will be denied and must be
resubmitted to obtain reimbursement.
The basis for granting or denying approval shall be whether the item or service is
medically necessary, whether a less expensive service would adequately meet the
Member’s needs, and whether the proposed item or service conforms to
commonly accepted standards in the dental community.
During the prior authorization process it may become necessary to have your
patient clinically evaluated. If this is the case, you will be notified of a date and
time for the examination. It is the responsibility of the participating dentist to
ensure attendance at this appointment. Patient failure to keep an appointment
will result in denial of the treatment.
Continued on next page
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1.3 DETAIL OF SCREENS AND SERVICES, Continued
Dental service
retrospective
review
Services that would normally require Prior Authorization, but are performed in an
emergency situation due to the following circumstances, will have a retrospective
review:
• Retroactive Medicaid Eligibility
• Retrospective review is available for Medicaid members in instances where
it is in the dental practitioner’s opinion that a procedure may subject the
member to unnecessary or duplicative service if delivery of the service is
delayed until prior authorization is granted.
Retrospective review needs to be submitted with the appropriate documentation
by the provider within ten (10) business days of the date the service is performed.
Types of documentation required, but not limited to, are:
• Radiographs (pre-op, post-op or opposing arch x-rays as indicated in the
exhibits)
• Narrative of medical necessity
• Period charting
Any claims for retrospective review submitted without the required documents
will be denied and must be resubmitted for reimbursement. If the procedure(s)
does not meet medical necessity criteria upon review by Utilization Management,
the prior authorization request will be denied and the provider will not be
reimbursed for the service by WVFH or the member.
The Dental Consultants reviews the documentation to ensure the services
rendered meet the clinical criteria requirements. Once the clinical review is
completed, the claim is either paid or denied within twenty (20) calendar days for
clean claims and notification will be sent to the provider via the provider
remittance statement.
Dental services
in hospital
setting or ASC
Dentists can obtain prior approval for dental procedures performed in a hospital
outpatient setting or an Ambulatory Surgical Center (ASC).
Providers seeking information on this process can contact the Member Service
Representative for specific details on how to obtain pre-authorization for services
to be done in a hospital outpatient setting or an ASC.
Continued on next page
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1.3 DETAIL OF SCREENS AND SERVICES, Continued
Vision
testing
The chart should be affixed to a light-colored wall, with adequate lighting (10-30
foot candles) and no shadows. Ordinary room lighting typically does not provide
adequate lighting and the chart will need a light of its own. The 20-foot line on the
chart should be set at approximately the level of the eyes of a six-year-old.
Placement of the child must be exactly 20 feet. Sites that do not have a 20-foot
distance at which to test should obtain a 10-foot Snellen chart rather than convert
the 20-foot chart. The eye not being tested must be covered with an opaque
occluder; several commercial varieties are available at minimal cost, or the
practitioner may improvise one, but the hand may not be used, as it leads to
inaccuracies. In older children who seem to have difficulty or in young children,
bring the child up to the chart (preferably before testing) and explain the
procedure.
For screening, the tester should start with the big E (20-foot line) and then
proceed down rapidly line-by-line, as long as the child reads one letter per line,
until the child cannot read. At this critical level, the child is tested on every letter
on that line or adjacent line. Passing is reading a majority of letters in a line. It is
not necessary to test for every letter on the chart. Tests for hyperopia may be
done but are not required.
Referral System
Children seven (7) years of age and over must be referred if vision in either eye is
20/30 or worse. A child may be referred if the parent complains or if the doctor
discovers a medical reason. (Generally, sitting close to the television without other
complaints, and with normal acuity, is not a reason for referral.) Children failing a
test for hyperopia may be referred.
Children already wearing glasses must be tested with their glasses. If they pass,
record the measurement; nothing further needs to be done. If they fail, refer for
re-evaluation to a WVFH Network specialist, preferably to the vision practitioner
who prescribed the lenses, regardless of when they were prescribed.
If the practitioner is unable to render an eye examination in a child nine years of
age or older, because of the child’s inability to read the chart or follow directions
(e.g. a developmentally challenged child), refer this child to a Network
ophthalmologist or optometrist.
Hearing
screening
Sweep audiometry is the most frequently used examination and must be
administered to every screened child within the first month of life, and after the
age of three through a hearing test.
Tuning forks and un-calibrated noisemakers are not acceptable for hearing testing.
Continued on next page
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1.3 DETAIL OF SCREENS AND SERVICES, Continued
Hearing
screening
(continued)
For children under five years of age, observation should be made of the child’s
reaction to noises and to voices, unless the child is sufficiently cooperative to
actually do the audiometry. For audiometry, explain the procedure to the child.
For small children, present it as a game. Present one tone loud enough for the
child to hear, and explain that when it is heard, the child should raise his/her hand
and keep it raised until the sound disappears. Once the child understands,
proceed with the test. Doing one ear at a time, set the decibel level at 25, and
testing at 500 HZ. Then go successively to 1,000, 4,000, and 6,000. Repeat for the
other ear. The quietest room at the site must be used for testing hearing.
Referral System
Any cooperative child failing sweep audiometry at any two frequencies must be
referred. If a child fails one tone, retest that tone with threshold audiometry to be
certain it is not a severe single loss. To be certain of the need for referral, the
practitioner must immediately retest all failed tones by threshold audiometry, or,
if there is question about the child’s cooperation or ability at the time of testing,
bring the child back for another sweep audiometry before referring.
Please remember that audiometers must be periodically (at least annually)
calibrated for accuracy.
Developmental/
behavioral
appraisal
Since children with slow development and abnormal behavior may be able to be
successfully treated if treatment is begun early, it is important to identify these
problems as early as possible. Questions must be included in the history, which
relate to behavior and social activity as well as development. Close observation is
also needed during the entire visit for clues to deviations in those areas.
If the practitioner suspects developmental delay he/she is required to refer the
child to West Virginia Birth to Three at 1-866-321-4728, for appropriate
eligibility determination for early intervention services.
Below Five Years of Age
In addition to history and observation, a developmental evaluation is required. In
children who are regular patients of the practitioner site, this may consist of
ongoing recording in the child’s chart of developmental milestones sufficient to
make a judgment on developmental progress. In absence of this, the site may
elect to conduct a Denver Developmental Screening Test as its evaluation
utilizing the Denver II Form.
Marked slowness in any area is cause for a referral to a Network specialist, e.g.
developmental center, a MH/MR agency, a developmental specialist, a pediatric
neurologist or a psychologist. If only moderate deficiencies in one or more areas
are found, the practitioner must retest the child in 30-60 days.
Continued on next page
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1.3 DETAIL OF SCREENS AND SERVICES, Continued
Developmental/
behavioral
appraisal
(continued)
Social Activity/Behavior
Questions should be asked to determine how the child relates to his family and
peers and whether any noticeable deviation in any of his/her behavior exists. The
DASE test may be used as an evaluation.
Five Years and Older
Since the usual developmental tests are not valid at this age, observation and
history must be used to determine the child’s normality in the areas listed below.
Each child should be checked and recorded appropriately. Major difficulty in any
one area, or minor difficulty in two or more areas, is cause for referral to a
Network behavioral health professional for further diagnosis.
1. Social Activity/Behavior – Does the child relate with family, teachers, and
peers appropriately? Has the child had a change in behavioral, specifically a
loss of interest in usual and preferred activities?
2. School – Is the child’s grade level appropriate for his/her age? Has the child
been held back in school? Has the child demonstrated a decrease in
academic work, social function, and/or sports?
3. Peer Relationships
4. Physical/Athletic Dexterity
5. Sexual Maturation – Tanner Score. A full explanation of Tanner observations
and scoring is found below.
6. Speech – DASE Test. If there is a problem in this area, record accordingly,
refer appropriately.
Anemia
screening
A hemoglobin or hematocrit must be done at 12 months of age and for females
once after the onset of menses. Subsequent testing should be at the practitioner’s
discretion, and based on the member’s history and presenting complaints.
Blood lead
level screening
All children must receive a screening blood lead test at 12 months and 24 months
of age. Children between the ages of 36 months and 72 months of age must
receive a screening blood lead test if they have not been previously screened for
lead poisoning. Please refer to the HealthCheck Program Periodicity Schedule for
further clarification.
The Center for Disease Control requires the use of a blood lead test when
screening children for lead poisoning. A blood lead screening should be done by a
blood lead measurement of either a venous or capillary (finger stick) blood
specimen.
Continued on next page
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1.3 DETAIL OF SCREENS AND SERVICES, Continued
Blood lead
level screening
(continued)
Recommended Follow-Up Services For Children With Elevated Diagnostic*
Blood Lead Levels: If the result is greater than or equal to 10mcg/dl, see if it was
done by finger stick or venous puncture. If the screening test was a finger stick then
a venous specimen for a confirmation needs completed (see following Table 1 for
the recommended schedule for obtaining a confirmatory venous sample.)
Table1: Recommended Schedule for Obtaining a confirmatory Venous Sample
SCREENING TEST RESULT (mcg/dl)
Perform a confirmation test within:
1
2
4
6
≥
3
1 week – 1 month*
48
24
Immediately as an emergency lab test
*The higher the BLL on the screening test, the more urgent the need for confirmatory testing.
WV CLPPP CASE MANAGEMENT PROTOCOL
Time Frames for Environmental Investigation and Other Case Management Activities
According to a Child’s Blood Lead Level
BLOOD LEAD LEVEL
(mg/dl)
10-14
15-19
20-44
45-70
70 or higher
TIME FRAME FOR
BEGINNING
INTERVENTION
ACTIONS
Within 30 days
• Provide caregiver lead education.
• Refer the child for social services if necessary.
• Make Priority Environmental.
• Referral for investigation and control current lead hazards.
Above actions, plus:
• If BLLs persist (i.e., 2 venous BLLs in this range at least 3
months apart) or increase, proceed according to actions
for BLLS 20-44.
• Make Priority Environmental.
• Referral for investigation and control current lead hazards.
Above actions, plus:
• Provide coordination of care (case management).
• Make Priority Environmental.
• Referral for investigation and control current lead hazards.
Above actions.
Above actions, plus hospitalize child for chelation therapy
immediately.
Within 2 weeks
Within 1 week
Within 48 hours
Within 24 hours
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1.3 DETAIL OF SCREENS AND SERVICES, Continued
Blood lead
level screening
(continued)
Environmental Investigation of Lead
Environmental investigation as required by EPSDT and the 1991 Center for
Disease Control Prevention of Lead Poisoning Guidelines and Abatement of Lead
Sources are to be referred to the appropriate entity funded for this task. Contact
the National Lead Information Center (NLIC) line at 1-800-424-LEAD (5323).
Use the WVFH Member Outreach Form, also found in this manual’s Appendix, to
notify WVFH’s Growing Up Outreach staff of the need for follow-up. WVFH can
also assist with issues regarding elevated blood lead levels or regarding noncompliance.
If the screening indicates the need for the member to be referred to a specialist, a
WVFH Referral Form must be completed. This form is also available in this
manual’s Appendix.
Immunizations
Both state and federal regulations require that immunizations be brought up to
date during health screens and any other visits the child makes to the office. The
importance of assessing the correct immunization status cannot be overly
stressed. In all instances, the practitioner’s records must show immunization
history and documentation must include the date of the immunization, the
signature of the person administering the immunization, and the name and lot
number of the antigen. This will provide the necessary basis for further visits and
immunizations.
Healthcare Effectiveness Data and Information Set (HEDIS) also evaluates Human
Papillomavirus Vaccine (HPV) for Female Adolescents. This measure will assess the
percentage of 13-year-old females who had three doses of the HPV vaccine. The
measure is designed to evaluate compliance with Centers for Disease Control and
Prevention and Advisory Committee on Immunization Practices immunization
guidelines.
WVFH follows recommended childhood immunization schedules approved by the
Centers for Disease Control and Prevention’s (CDC) Advisory Committee on
Immunization Practices (ACIP), the American Academy of Pediatrics, and the
American Academy of Family Physicians. To facilitate distribution of the most
current version of this schedule, it has been added to the WVFH’s website. A paper
copy is available upon request. For a paper copy, please contact the Provider
Services Department at 1-855-412-8002.
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1.3 DETAIL OF SCREENS AND SERVICES, Continued
Vaccines
for Children
(VFC) Program
Children under 21 years of age receiving Medicaid are eligible for Vaccines For
Children (VFC) Program. All PCPs will be reimbursed for the administration of any
vaccine covered under the VFC Program when a claim is received with the
appropriate immunization code.
Any procedures for immunizations not covered under the VFC Program, but
covered by WVFH, will be reimbursed fee-for-service.
Immunization
Registry
The West Virginia Statewide Immunization Information System (WVSIIS) helps
ensure that all West Virginia children, adolescents, and adults have current
immunizations. These shots provide protection from diseases like measles,
rotavirus, human papillomavirus, hepatitis, and pertussis (whooping cough).
This system creates a confidential, computerized information system that keeps
complete, up-to-date records that providers can access, resulting in higher
immunization rates and better patient care. State law requires all providers to
report all shots they administer to children under age 18 to WVSIIS within two
weeks.
Childhood and adolescent immunization reviews should be done at wellchild visits as well as during urgent problem-oriented visits.
For more information about this registry, please contact:
http://www.dhhr.wv.gov/oeps/deie/WVSIIS/Pages/default.aspx
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CHAPTER 2: PROVIDER RESPONSIBILITIES
UNIT 1: PCP’S ROLE
IN THIS UNIT
TOPIC
General Information
• PCP Patient Panel
• Prospective Care Management
• Addition of Newborns
• Processing PCP Change Requests
• Transfer of Medical Records
Appointment Standards
Immunizations
• Vaccines For Children (VFC) Program
• Immunization Registry
Oral Health Risk Assessment
Transfer of Non-Compliant Members
Coordination of Behavioral Health and Physical Health Services
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2.1 GENERAL INFORMATION
Introduction
The definition of a primary care practitioner (PCP) is a specific practitioner,
practitioner group or a certified registered nurse practitioner (CRNP) operating
under the scope of his/her licensure, and who is responsible for supervising,
prescribing, and providing primary care services; locating, coordinating, and
monitoring other medical care and rehabilitative services and maintaining
continuity of care on behalf of a Medicaid member. The PCP is responsible for the
coordination of a member’s health care needs and access to services provided by
hospitals, specialty care practitioners, ancillary services and other health care
services.
Although members may obtain some health care services by self-referral, the
majority of their health care services are obtained either directly from or upon
referral by the PCP. With the exception of self-referred services, all of the
member’s care must be provided or referred by the PCP except in a true medical
emergency when time does not permit a member to contact their PCP. To assure
continuity and coordination of care, when a member self-refers for care, a report
should be forwarded to the PCP. By focusing all of a member’s medical decisions
through the PCP, WVFH is able to provide comprehensive and high quality care in
a cost-effective manner.
Our goal is to work together with a dedicated group of practitioners to make a
positive impact on the health of our Membership and truly make a difference.
PCP Patient
Panel
Each member in a family has the freedom to choose any Network PCP, and a
member may change to another primary care practitioner should a satisfactory
patient-practitioner relationship not develop. A PCP agrees to accept a minimum
number of WVFH members, as specified in the State Burau of Medical Services
(BMS) contract, to their patient panel at each authorized office location without
regard to the health status or health care needs of such members and without
regard to their status as a new or existing patient to that practice or location.
The primary care practitioner (PCP) may, upon sixty (60) days prior written notice
to Highmark West Virginia, state in writing that they do not wish to accept
additional members. The written request excludes members already assigned to
the PCP’s practice, including applications in process.
Prospective
Care
Management
Through WVFH’s model of Prospective Care Management, we emphasize the
importance of extensive member outreach, community involvement, and
physician practice engagement. We support the efforts of physician practices in
delivering the highest quality of care to members.
Continued on next page
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2.1 GENERAL INFORMATION, Continued
Addition of
newborns
When a member selects WVFH, the member’s effective date is usually the 1st of
the month. When the member is a newborn, the member may be added any time
of the month. Because newborn information is reported to WVFH retroactively,
newborns will show up as a retroactive addition to the primary care practitioner’s
monthly panel listing. Newborns will be effective on their date of birth or the date
the newborn was added to the member’s grant.
Processing
PCP change
requests
When a member wishes to change his or her primary care practitioner (PCP), the
change is processed under the following guidelines:
Transfer
of medical
records
PCPs are required to transfer member medical records or copies of records to
newly designated PCPs within ten (10) business days from receipt of the request
from the West Virginia Bureau for Medical Services (“BMS”), its agent, the member
or the member’s new PCP, without charging the member.
• When the request is received prior to the 25th of the current month, the
new effective date will be the first of the following month. For example, if a
member’s request is received on October 7th, the member will be effective
November 1st with the new PCP.
• When the request is received on or after the 25th of the current month,
the new effective date will be the first of the subsequent month. For
example, if a member’s request is received on October 28th, the member will
be effective December 1st with the new PCP. If the member requests to
change his or her PCP immediately, an exception to the above guidelines
can be made if the situation warrants.
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2.1 APPOINTMENT STANDARDS
WVFH PCP
appointment
standards
PCPs agree to meet WVFH’s appointment standards as follows:
STANDARD
MEASUREMENT
Wait time for an Emergent
Appointment
Immediately seen or referred to an
emergency facility
Wait time for Urgent Care
appointment
Within 48 hours
Wait time for Routine Appointments
Within 21 business days of request
Wait time for a Health
Assessment/General Physical
Examinations, and First Examinations
Within 3 weeks of enrollment
After-Hours Care Accessibility
Access to practitioner 24 hours/7 days
a week. A live person, recording, or
auto attendant will direct patients in
the case of a true emergency to call
911 or go to the nearest Emergency
Room. An on-call physician is available
after-hours.
Wait time for first appointment with
member who is Supplemental
Security Income (SSI) or SSI-related
consumer
Within forty-five (45) days of
enrollment unless the member is
already in active care with a PCP or
specialist.
Wait time for initial prenatal visit
(applies to PCPs who provide prenatal
care)
Within fourteen (14) days of the
member being identified as being
pregnant.
Missed Appointment
Conduct outreach whenever a
member misses an appointment and
document in the medical record.
Three attempts with at least one
attempt to include a telephone call.
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2.1 IMMUNIZATIONS
Vaccines For
Children (VFC)
Program
Children under 21 years of age receiving Medicaid are eligible for Vaccines For
Children (VFC) Program. All PCPs will be reimbursed for the administration of any
vaccine covered under the VFC Program when a claim is received with the
appropriate immunization code. Any procedures for immunizations not covered
under the VFC Program, but covered by WVFH, will be reimbursed fee-for-service.
Immunization
Registry
The West Virginia Statewide Immunization Information System (WVSIIS) helps
ensure that all West Virginia children, adolescents and adults have current
immunizations. These shots provide protection from diseases like measles,
rotavirus, human papillomavirus, hepatitis and pertussis (whooping cough).
This system creates a confidential, computerized information system that keeps
complete, up-to-date records that providers can access, resulting in higher
immunization rates and better patient care. State law requires all providers to
report all shots they administer to children under age 18 to WVSIIS within two
weeks.
Childhood and adolescent immunization reviews should be done at wellchild visits as well as during urgent problem-oriented visits.
The provider signs an enrollment packet, has training, and determines the access
option best for his/her practice. Based on this, the provider can begin using
WVSIIS.
FOR MORE
INFORMATION
For more information about the Immunization Registry, please call the WVSIIS
Help Desk at 1-877-408-8930, or visit their website at:
http://www.dhhr.wv.gov/oeps/deie/WVSIIS/Pages/default.aspx
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2.1 ORAL HEALTH RISK ASSESSMENT
Topical
fluoride
varnish
Tooth decay remains one of the most common childhood diseases and is also one
of the most preventable. Primary Care Practitioners (PCPs) can help prevent tooth
decay by providing topical fluoride varnish in the office for their WVFH Medicaid
patients under the age of three.
Training
required
WVFH reimburses primary care providers who have been certified through a faceto-face training for fluoride varnish application offered through the West Virginia
University School of Dentistry for the application of fluoride varnish to children
ages 6 months to 36 months (3 years) who are at high risk of developing dental
caries. The application of the fluoride varnish should include communication with
and counseling of the child’s caregiver, including a referral to a dentist.
To receive payment for this service, the provider must complete training through
West Virginia University School of Dentistry.
FOR MORE
INFORMATION
Please refer to this manual’s Chapter 3, Unit 2: Claims and Billing Information for
billing instructions.
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2.1 TRANSFER OF NON-COMPLIANT MEMBERS
Policy
PCPs agree (a) not to discriminate in the treatment of his/her patients, or in the
quality of services delivered to WVFH members on the basis of race, sex, age,
religion, place of residence, health status or source of payment; and (b) to
observe, protect and promote the rights of members as patients. PCPs shall not
seek to transfer a member from his/her practice based on the member’s health
status. However, a member whose behavior would preclude delivery of optimum
medical care may be transferred from the practitioner’s panel. WVFH’s goal is to
accomplish the uninterrupted transfer of care for a member who cannot maintain
an effective relationship with a given practitioner.
Additionally, in order to assist Network practitioners in the management of
members who violate office policy in regard to scheduled appointments, WVFH
has instituted the following Member No-Show Policy:
WVFH will recognize the individual practitioner’s written office policy in
regard to scheduled appointments. Network practitioners are responsible
for recording no-show appointments in the member’s medical record.
When a transfer is being conducted due to member no-show, the practitioner’s
notification should indicate that the practitioner wants to transfer the member to
another PCP’s practice.
Written
transfer
requests
required
Should an incidence of inappropriate behavior or member non-compliance with
no-show policies occur, and transfer of the member is desired, the practitioner
must send a letter requesting that the member be removed from his/her panel
including the member’s name and WVFH ID Number, and, when applicable, state
their no-show policy, and the member(s) who has (have) violated the policy to the
Provider Services Department at:
West Virginia Family Health
Attention: Provider Services
P.O. Box 22190
Pittsburgh, PA 15222
All written requests are forwarded to the Enrollment Department within 48 hours
of receipt. The Enrollment Department notifies the original practitioner in writing
when the transfer has been completed. If the member requests not to be
transferred, the PCP will have the final determination regarding continuation of
primary care services.
PCPs are required to provide emergency care for any WVFH member
dismissed from their practice until the member transfer has been completed.
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2.1 COORDINATION OF BEHAVIORAL HEALTH AND PHYSICAL
HEALTH SERVICES
Coordination
requirements
Behavioral health or drug and alcohol services are covered by WVFH, including
emergency room services, home health care, pharmacy services, and emergency
transportation services. WVFH is responsible for all emergency transportation in
an ambulance to an emergency room and to a behavioral health facility. All
prescribed medications are dispensed through the WVFH pharmacy network. This
includes drugs prescribed by both physical health and behavioral health
practitioners.
Emergency services provided in general hospital emergency rooms are the
responsibility of WVFH regardless of the diagnosis or services provided. The only
exception is for emergency room evaluations for voluntary or involuntary
commitments pursuant to the 1976 Mental Health Procedures Act (50 P.S. Section
7101, et. Seq.), which are the responsibility of the BH-MCO.
Both primary care practitioners (PCPs) and behavioral health clinicians have the
obligation to coordinate care of mutual patients in accordance with state and
federal confidentiality laws and regulations. This includes, but is not limited to:
obtaining appropriate releases to share clinical information; making referrals for
social, vocational, education or human services when a need is identified through
assessment; notifying each other of prescribed medications; and being available
for consultation when necessary.
Referrals are not necessary for members to receive the services of a behavioral
health practitioner.
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CHAPTER 2: PROVIDER RESPONSIBILITIES
UNIT 2: SPECIALTY CARE PRACTITIONER
IN THIS UNIT
TOPIC
Verifying Eligibility
Referrals Required for Specialty Care
Appointment Standards
Reimbursement
Emergency Services
Specialists Functioning as Primary Care Practitioners
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2.2 VERIFYING ELIGIBILITY
WVFH Provider
Digital Voice
Assistant
(DIVA)
Due to frequent changes in a member’s eligibility, specialty care practitioners
must verify eligibility prior to rendering services to assure reimbursement. This
can be done by calling the West Virginia Family Health (WVFH) Provider Digital
Voice Assistant (DIVA) system:
Available 24 hours a day, seven days a week at 1-888-907-8002.
Steps in
verifying
eligibility via
WVFH DIVA
To verify Enrollee eligibility at each visit, practitioners follow a few simple steps,
which are listed below:
TO VERIFY ENROLLEE ELIGIBILITY QUESTION:
• Press 1 to verify eligibility.
• Enrollee Identification Number?
 Press 1 to verify eligibility using the patient’s social security number.
When prompted, enter the patient’s 9-digit social security number,
and then press the # key.
 Press 2 to verify eligibility using the patient’s WVFH Enrollee
identification number. When prompted, enter the patient’s 8-digit
WVFH identification number.
 Press 3 to verify eligibility using the patient’s West Virginia Medicaid
recipient identification number. When prompted, enter the patient’s
West Virginia Medicaid recipient identification number.
 Press 0 to speak to a Provider Services Representative.
 Press 9 to repeat the menu.
• Verification of Date Question
 Press 1 to verify whether the patient is eligible TODAY or the PCP
assigned to Enrollee TODAY
 Press 2 to verify whether the patient is eligible on a specific date.
Enter the date using the 2-digit month, 2-digit day, and 4-digit year.
o Press 1 if the repeated date is correct.
o Press 2 if the repeated date is incorrect.
o Press 9 to listen to the instructions again.
 Press 0 to speak to a Provider Services Representative.
Continued on next page
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2.2 VERIFYING ELIGIBILITY, Continued
Steps in
verifying
eligibility via
WVFH DIVA
(continued)
ADDITIONAL INSTRUCTIONS QUESTION:
• Press 1 to receive additional information about the patient/Enrollee
(includes the spelling of the Enrollee’s first and last name).
• Press 2 to receive the patient’s PCP name and telephone number (includes
the spelling of the provider’s name and phone number).
• Press 3 to fax information regarding the patient whose eligibility is being
verified. You will be asked to enter the fax number for which you wish to
receive the eligibility verification.
• Press 4 to verify eligibility for another patient/Enrollee.
• Press 5 to exit.
• Press 6 to return to the menu of automated services.
• Press 9 to listen to the instructions again.
• Press 0 to speak to a Provider Services Representative.
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2.2 REFERRALS REQUIRED FOR SPECIALTY CARE
PCP referral
requirements
All WVFH members must obtain a valid referral from their primary care
practitioner (PCP) prior to receiving specialty services except for the services that
can be accessed by a self-referral.
Neonatologist
exception
The only exception to this is for Neonatologists who may issue a referral to other
Network hospitals and/or specialists for babies discharged from the NICU who
require service before seeing their PCP. Referrals should be issued under the
baby’s ID number. If the baby does not have an ID number, the practitioner should
call WVFH’s Utilization Management Department for authorization.
Verifying
PCP referrals
via telephone
WVFH members receive specialty care services from Network practitioners
through a telephonic referral issued by the primary care practitioner (PCP) office.
If additional
specialty care
is needed
If additional specialty care not authorized on the original referral is needed, please
contact the member’s PCP to obtain another WVFH referral. However, if the
procedures are being performed on the same date of service and in the same
office as indicated on the original referral, another referral is not necessary.
WVFH’s IVR may be used by PCPs and OB/GYN practitioners to issue a referral, or
by specialty care practitioners to verify the existence of a valid referral by calling
1-888-907-8002.
The specialist is responsible for providing written correspondence to the
member’s PCP for coordination and continuity of care.
Is visit an
EPSDT
referral?
Providers must make reasonable efforts for every member under 21 years of age
to determine whether a visit to the provider‘s office stems from an EPSDT referral
by asking the referring provider, clinic, or member.
If the visit is the result of an EPSDT screening, the appropriate space on the claim
must be marked "yes" to indicate a referral was the source of the visit. Likewise,
the appropriate space on the claim must be marked no if the information cannot
be obtained or is not the result of a screening.
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2.2 APPOINTMENT STANDARDS
Specialty care
appointment
standards
Specialty care practitioners agree to meet WVFH’s appointment standards, as
follows:
PRACTITIONER TYPE
REQUIREMENT
STANDARD
Specialist
Wait time for an emergent
appointment
Immediately seen or referred to an
emergency facility
Specialist
Wait time for an Urgent Care
appointment
Within 48 hours
Specialist
Wait time for Routine
Appointments
Within 21 business days
Specialist
Wait time in the waiting room for
routine care
Specialist
Missed appointment
Average office waiting time no
more than thirty (30) minutes or at
any time no more than up to one
(1) hour when the physician
encounters an unanticipated
Urgent Medical Condition visit or is
treating a member with a difficult
medical condition need.
Conduct outreach whenever a
member misses an appointment
and document in the medical
record. Three attempts with at least
one attempt to include a telephone
call.
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2.2 REIMBURSEMENT
Payment
Payment by WVFH is considered payment in full. Members will be held harmless
for the costs of all Medicaid-covered services provided except for applicable
cost-sharing obligations.
Member
Billing Policy
Under no circumstance including, but not limited to, non-payment by WVFH for
approved services, may a provider bill, charge, collect a deposit from, seek
compensation, remuneration, or reimbursement from or have any recourse
against a WVFH member beyond the rates established by the state-wide
copayment schedule noted in this manual’s Chapter 1, Unit 2 (page 2) and subject
to the copay prohibitions also detailed in Chapter 1, Unit 2 (page 5).
Non-covered
services
Practitioners may directly bill Members for non-covered services; provided,
however, that prior to the provision of such non-covered services, the practitioner
must inform the Member:
(i) of the service(s) to be provided;
(ii) that WVFH will not pay for or be liable for said services;
(iii) of the Member’s rights to appeal an adverse coverage decision as fully set
forth in the Provider Manual; and
(iv) absent a successful appeal, that Member will be financially liable for such
services.
FOR MORE
INFORMATION
Refer to this manual’s Chapter 3, Unit 2: Claims and Billing for additional
information regarding submission of claims.
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2.2 EMERGENCY SERVICES
Notification
requirements
if directing a
member to ER
All WVFH members are informed that they must contact their PCP for
authorization prior to seeking treatment for non-life or limb threatening
conditions in an emergency room. However, WVFH realizes that there are
situations when a member is under the care of a specialty care practitioner for a
specific condition, such as an OB/GYN during pregnancy, and the member may
contact the specialist for instructions.
If a specialty care practitioner directs a member to an emergency room for
treatment, the specialty care practitioner is required to immediately notify the
hospital emergency room of the pending arrival of the patient for emergency
services. The specialty care practitioner is required to notify the PCP of the
emergency services within one (1) business day when the emergency room visit
occurs over a weekend. Every effort should be made to direct members to WVFH
Network hospitals.
Chronic care
health home
notification
If the member is participating in a chronic care health home, the health home
must be notified of any use of emergency services and be notified of any inpatient
admission or discharge of a health home member that the MCO learns of through
its inpatient admission initial authorization and concurrent review processes
within 24 hours.
Emergency
medical
screening
exam
requirements
A medical screening examination needed to diagnose a member’s emergency
medical condition must be provided in a hospital-based emergency department
that meets the requirements of the Emergency Medical Treatment and Active
Labor Act (EMTALA)(42 CFR 489.20, 489.24 and 438.144(b) & (c)). WVFH will
reimburse both the physician’s services and the hospital’s emergency services,
including the emergency room and its ancillary services.
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2.2 SPECIALISTS FUNCTIONING AS PRIMARY CARE
PRACTITIONERS
WVFH
approval
required
Specialists may function as a PCP for specific members with complex illnesses or
conditions. In order for a specialist to function as a PCP, the specialist must be
approved by the WVFH Medical Director.
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CHAPTER 2: PROVIDER RESPONSIBILITIES
UNIT 3: OB/GYN SERVICES
IN THIS UNIT
TOPIC
General Information
• Member Self-Referral to OB/GYN
• PCPs & Routine Gynecological Services
• Referrals to Specialty Care Practitioners
• Diagnostic Testing
• Maternity Authorization
• Newborns
Appointment Standards
Prenatal Risk Screening Instrument (PRSI)
Coding Maternity-Related Services
Family Planning Guidelines and Billing
Medicaid Sterilization/Hysterectomy Consent Forms
Abortion Services
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2
2
2
2
2
3
4
5
6
8
9
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2.3 GENERAL INFORMATION
Member
self-referral
to OB/GYN
To eliminate any perceived barrier to accessing obstetrical/gynecological
(“OB/GYN”) services, West Virginia Family Health (“WVFH”) allows all female
members to self-refer to any Network OB/GYN for any OB/GYN related condition,
not just for an annual exam or suspected pregnancy. When a member self-refers
to the OB/GYN, the OB/GYN’s office is required to verify eligibility of the member.
WVFH members may also self-refer for family planning services.
PCPs & routine
gynecological
services
WVFH permits its primary care practitioners (PCPs) to perform routine
gynecological exams and pap tests and provide care during pregnancy if they are
so trained and equipped in their office. PCPs that provide obstetrical services must
bill in accordance with WVFH guidelines and may only provide obstetrical services
to those patients assigned to their panel.
Referrals to
specialty care
practitioners
If an OB/GYN determines that assessment or treatment by another specialty care
practitioner is necessary, the OB/GYN is required to contact the member’s primary
care practitioner (PCP) to request a referral to a specialist. The OB/GYN practitioner
is responsible for providing written correspondence to the member’s PCP for
coordination and continuity of care.
The OB/GYN cannot refer a member directly to another specialty care practitioner
with the exception of Network Perinatologists.
Diagnostic
testing
Fetal non-stress tests and obstetrical ultrasounds can be performed in the
OB/GYN’s office or at a hospital without an authorization or a referral from WVFH.
A referral is not required for mammograms or other testing or procedures
performed at a Network hospital. Only a prescription is needed.
Maternity
authorization
In addition to the authorization procedure for inpatient admissions found in this
manual’s Chapter 2, Unit 4: Hospital Services, WVFH requires the provider to
complete a Maternity Outcome Authorization Form within two (2) business days
of the delivery. The receipt of this form lets WVFH know the mother has
delivered, as well as alerting us that the baby was born and needs to be added to
the system.
This form can also be found in this manual’s Appendix, as well as on the WVFH
website at www.wvfh.com.
Continued on next page
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2.3 GENERAL INFORMATION, Continued
Newborns
Newborns of WVFH mothers will be covered for services rendered during the
neonatal period. All charges for newborns that become enrolled in the plan, other
than hospital bills covering the confinement for both mom and baby, are
processed under the newborn name and newborn WVFH Identification Number.
WVFH is responsible for all charges during the inpatient newborn stay if such
newborn is born to a mother who is a current WVFH member until the newborn’s
discharge.
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2.3 APPOINTMENT STANDARDS
OB/GYN
standards
Appointment standards for OB/GYN practitioners are as follows:
REQUIREMENT
STANDARD
Wait time for initial prenatal visit
Within fourteen (14) days of the member being identified as
being pregnant.
• 1st Trimester – within 14 days
• 2nd Trimester – within 7 days
• 3rd Trimester – within 3 days
High-risk pregnancies
Within twenty-four (24) hours of identification of high-risk by
WVFH or the maternity care provider, or immediately if an
emergency exists.
Standards for
all specialists
Additional standards apply to all specialists, including OB/GYNs:
PRACTITIONER TYPE
REQUIREMENT
STANDARD
Specialist
Wait time for an emergent
appointment
Immediately seen or referred to an
emergency facility
Specialist
Wait time for an Urgent Care
appointment
Within 48 hours
Specialist
Wait time for Routine
Appointments
Within 21 business days
Specialist
Wait time in the waiting room for
routine care
Specialist
Missed appointment
Average office waiting time no
more than thirty (30) minutes or at
any time no more than up to one
(1) hour when the physician
encounters an unanticipated
Urgent Medical Condition visit or is
treating a member with a difficult
medical condition need.
Conduct outreach whenever a
member misses an appointment
and document in the medical
record. Three attempts with at least
one attempt to include a telephone
call.
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2.3 PRENATAL RISK SCREENING INSTRUMENT (PRSI)
PRSI Form
requirements
The first visit with an obstetrical patient is considered to be the intake visit, or if a
patient becomes a WVFH member during the course of her pregnancy, her first
visit as a WVFH member is considered to be her intake visit.
At the intake visit, a West Virginia Prenatal Risk Screening Instrument Form (Form
Number: WVDHHR/BPH/OMCFH/DPWH PRSI 04/27/2012) should be immediately
faxed to WVFH’s Maternity Care Management at 1-855-430-9847 or emailed to
WVFH via WVFH’s secure email portal and then filed in the member’s medical
record. This statewide form is available in this manual’s Appendix and also at:
http://www.wvdhhr.org/mcfh/WV_PrentalRiskScreeningInstrument2012.pdf
The WV Prenatal Risk Screening Instrument (PRSI) should be updated at the
28-32 week visits and also at the post-partum visit. These two updates should
also be faxed to WVFH immediately following completion.
Purpose of the
PRSI Form
The purpose of the PRSI Form is to help identify risk factors early in the pregnancy
and engage the woman in care management. For that reason, the PRSI Form must
be faxed to WVFH’s Maternity Care Management department at 1-855-430-9847
within 2-5 business days of the intake visit.
PRSI required
for intake visit
claim
The PRSI Form is not a claim. However, the PRSI Form must be received by WVFH
in order to process the claim for the intake visit. Please submit claims within 365
days to receive payment for the intake package.
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2.3 CODING MATERNITY-RELATED SERVICES
Prenatal
visits
West Virginia Medicaid will not reimburse for global maternity-related procedure
codes or bundled services codes because Medicaid members often change
physicians or managed care entities during maternity care, which greatly
complicates or precludes the use of global codes to pay for maternity care.
Under the per visit reimbursement structure, the following procedure codes
should be used when billing WVFH: all prenatal visits and dates of service must be
included on the claim form and identified with Evaluation and Management code
(99201 – 99215) ONLY. The TH modifier must follow the code in the first position
on the claim form.
Delivery
Delivery charges must be identified with CPT codes.
Initial Prenatal
Visit Incentive
WVFH will reimburse providers a bonus payment of $200 for initial prenatal risk
assessment visits rendered within the first trimester. Please bill as indicated below
to receive the bonus payment:
• The initial prenatal visit MUST be rendered within the first trimester and
the West Virginia Prenatal Risk Screening Instrument (PRSI) Form must be
completed during the visit and faxed to WVFH’s Maternity Care
Management department at 1-855-430-9847 within 2-5 business days of
the visit.
• Procedure code T1001-HD (Initial Risk Assessment) must be reported
on the same claim form as the maternity visit (99213-TH or T1015-TH)
together on the same claim form to allow the bonus payment.
The bonus payment will not be paid if both codes/modifiers referenced
above are not reported on the same claim. The PRSI Form is not a claim form;
however, the form must be received by WVFH and documented in our claims
system prior to receipt of the claim to allow the appropriate bonus and intake visit
payment.
The initial prenatal visit MUST be rendered within the first trimester and the PRSI
must be completed during the visit and faxed to WVFH’s Maternity Care
Management department at 1-855-430-9847 within 2-5 business days of the
visit.
Continued on next page
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2.3 CODING MATERNITY-RELATED SERVICES, Continued
If first visit is
not within the
first trimester
If the member’s first prenatal visit doesn’t occur within the first trimester then
code 99429-HD should not be billed. However, the first visit with an obstetrical
patient is considered to be the intake visit. If a patient becomes a WVFH member
during the course of her pregnancy, her first visit as a WVFH member is considered
to be her intake visit. At the intake visit, a PRSI Form must be completed and a
claim submitted with code T1001-U9 for reimbursement.
Billing
instructions
Billing instructions for Federally Qualified Health Centers (FQHCs)/Rural
Health Centers (RHCs):
• If the PRSI was completed in the first trimester, report the services as
follows:
 T1015 -- Contracted rate or rate normally billed;
 T1001-U9 (Initial Risk Assessment) -- $200.00; and
 99429- HD -- $0.00
• If the PRSI was not completed within the first trimester, bill as follows:
 T1015 – charge should be encounter rate or rate normally billed; and
 T1001-U9 -- $200.00 (NO PAYMENT WILL BE MADE – incentive is only
reimbursed within the first trimester)
Billing instructions for professional providers other than FQHCs/RHCs:
• If the PRSI was completed in the first trimester, report the services as
follows:
 99201-99215 only with the provider’s charge. The TH modifier must
follow the code in the first position on the claim form;
 T1001-HD (Initial Risk Assessment) -- $200.00; and
 99429-HD -- $0.00
• If the PRSI was not completed within the first trimester, bill as follows:
 99201-99215 TH – provider’s charge; and
 T1001-U9 -- $200.00 (NO PAYMENT WILL BE MADE - incentive is only
reimbursed within the first trimester)
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2.3 FAMILY PLANNING GUIDELINES AND BILLING
Guidelines
WVFH permits Enrollees to see any Network or non-Network practitioner for
Family Planning Services only. Non-network providers are asked to educate
members about the release of necessary medical data to WVFH. If a WVFH patient
presents for family planning benefits, practitioners need to be aware of the
following:
• The patient’s eligibility can be verified by calling 1-888-907-8002. Family
planning patients DO NOT need a referral from their PCP under federal
mandate.
• A family planning patient may self-refer to her OB/GYN for prenatal care if
she becomes pregnant.
Billing
When billing for family planning services, use the national standard codes. The FP
modifier must follow the code in the first position on the claim form.
When billing for contraceptives and family planning drugs for West Virginia Family
Health members, use the appropriate J code. When a valid J code is not available,
bill with an unspecified J code along with the NDC code and the number of units
administered.
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2.3 MEDICAID STERILIZATION/HYSTERECTOMY CONSENT FORMS
Surgical
consent forms
required for
hysterectomy
and voluntary
sterilizations
WVFH requires authorization for hysterectomies and voluntary sterilizations.
WVFH, in accordance with the West Virginia Medicaid guidelines, will continue to
require the completion of the State surgical consent forms for hysterectomies and
sterilizations:
• Hysterectomy Acknowledgment Form
• Sterilization Consent Form
Copies of these forms are also available in this manual’s Appendix.
The surgical consent forms (DHS-2510-ENG (11/93)) for voluntary sterilizations
must be completed and signed by the Enrollee thirty (30) days prior to the
surgery. The consent form is valid for 180 days.
Any provider requesting authorization for a sterilization must submit the signed
consent form at least seven (7) days prior to the scheduled procedure.
Urgent or
retrospective
authorizations
Urgent authorizations or retrospective authorizations can be made upon request
for sterilizations performed commensurate with a premature delivery or
emergency abdominal surgery. The same responsibilities for member and
providers still apply regarding completion of consent forms.
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2.3 ABORTION SERVICES
Pregnancy
termination
policy and
requirements
West Virginia Medicaid covers pregnancy termination when the attending
physician determines, in consultation with the member, that termination is
medically advisable. Before making the determination, the physician must discuss
the possible pregnancy termination with the member in light of her age, physical,
emotional, psychological, and familial circumstances relevant to the well-being of
the patient. Certification by the physician is required for payment.
The provider office must submit the Physician Certification for Pregnancy
Termination Form to WVFH’s Utilization Management department by fax at
1-855-430-9848 at least one hour before the procedure, unless an emergency
prevents prior submission of the form. The completed and signed form must
accompany all claim forms for pregnancy terminations.
This form is available in this manual’s Appendix and can also be accessed through
the West Virginia Medicaid website at www.wvmmis.com.
Reimbursement
WVFH cannot reimburse Medicaid providers for the services provided to
Mountain Health Trust or Mountain Health Bridge members under any reported
and verified abortion CPT codes. Abortion Services will be reimbursed under FeeFor-Service Medicaid.
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CHAPTER 2: PROVIDER RESPONSIBILITIES
UNIT 4: HOSPITAL SERVICES
IN THIS UNIT
TOPIC
Inpatient Admissions
Hospital Transfer Policy
Outpatient Surgery Procedures
Emergency Room
Ambulance Services
Billing and Reimbursement
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2.4 INPATIENT ADMISSIONS
Authorization
required for all
inpatient
admissions
In order for West Virginia Family Health (WVFH) to monitor the quality of care and
utilization of services by our members, all WVFH practitioners are required to
obtain an authorization number for all hospital admissions and certain outpatient
surgical procedures by contacting WVFH’s Utilization Management Department at
1-855-412-8003.
WVFH will accept the PCP, ordering practitioner, or the attending practitioner’s
request for an authorization of non-emergency hospital care; however, no party
should assume the other has obtained authorization. WVFH will also accept a call
from the hospital’s Utilization Review Department.
The Utilization Management Representative refers to the WVFH Medical Director if
criteria or established guidelines are not met for medical necessity. The ordering
practitioner is offered a peer review opportunity with the WVFH Medical Director
for all potential denial determinations.
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2.4 HOSPITAL TRANSFER POLICY
Transfer
policy
When a WVFH member requires hospitalization, WVFH’s policy is to have the
service rendered in a WVFH Network hospital. However, WVFH recognizes that it
may not be possible to follow this general policy when a member presents to the
closest medical facility due to a medical emergency. When the medical condition
of the member requires an admission to a non-Network hospital, the member will
be transferred within twenty-four (24) hours of stabilization, when appropriate.
In order to determine that the member is medically stable for transfer the WVFH
Utilization Management staff will concurrently monitor the condition of the
patient by communicating with the hospital’s Utilization Review staff and the
attending practitioner. WVFH will coordinate all necessary transportation for the
timely transfer of the member.
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2.4 OUTPATIENT SURGERY PROCEDURES
Verify if
authorization
is required
Network practitioners may utilize a hospital’s Short Procedure Unit (SPU) or
Ambulatory Surgery Unit (ASU) for any authorized medically necessary procedure.
Medical Necessity Reviews may be required for certain procedures. Please call
WVFH’s Utilization Management Department to verify if authorization is required
or refer to the Administrative References on WVFH’s website.
Should a request to perform an outpatient procedure be denied by WVFH, the
practitioner will issue written notification to the member and requesting provider.
Urgent requests are responded to immediately. Due to monthly changes in
member eligibility, WVFH recommends that authorization be requested at least
two (2) working days in advance when possible.
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2.4 EMERGENCY ROOM
Definition of
emergency
An emergency is defined as a medical condition manifesting itself by acute
symptoms of sufficient severity (including severe pain) such that a prudent
layperson, who possesses an average knowledge of health and medicine, could
reasonably expect the absence of immediate medical attention to result in:
(a) placing the health of the individual (or with respect to a pregnant woman,
the health of the woman or her unborn child) in serious jeopardy;
(b) serious impairment to bodily functions; or
(c) serious dysfunction of any bodily organ or part.
In all instances, when a member presents to an emergency room for diagnosis and
treatment of an illness or injury, the hospital’s pre-established guidelines allow for
the triage of illness and injury.
Conditions
requiring
emergency
treatment
The following conditions are examples of those most likely to require emergency
treatment:
Nonemergency
services
For applicable non-emergency services, a copay should be required from the
member. WVFH members have been informed, through the Member Handbook,
of general instances when emergency care is typically not needed. These are as
follows:
• Cold
• Rash
• Sore throat
• Bruises
• Small cuts and burns • Swelling
• Ear ache
• Cramps
• Vomiting
• Cough
•
•
•
•
•
•
•
•
•
Danger of losing life or limb
Poisoning
Chest pain and heart attack
Overdose of medicine or drug
Choking
Heavy bleeding
Car accidents
Possible broken bones
Loss of speech
•
•
•
•
•
•
•
•
•
Paralysis
Breathing problems
Seizures
Criminal attack (mugging or rape)
Heart attack
Blackouts
Vomiting blood
Dental traumatic injury
Relief of severe dental pain
Continued on next page
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2.4 EMERGENCY ROOM, Continued
Follow-up
care
All follow-up care after an emergency room visit must be coordinated through the
primary care practitioner (PCP). Members are informed via the Member Handbook
to contact their PCP for a referral for follow-up care in instances such as:
• Removal of stitches
• Changing of bandages
• Cast check
• Further testing
Emergencies are handled in the same manner whether in or out of the WVFH
service area. WVFH requests that Network practitioners inform WVFH by calling
WVFH’s Utilization Management Department whenever they learn that a member
has received care outside of the service area.
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2.4 AMBULANCE SERVICES
Emergent
ambulance
transportaton
Emergent transportation (911), including air ambulance, does not require
authorization by WVFH. WVFH considers emergent transportation as
transportation that allows immediate access to medical or behavioral health care
and without such access could precipitate a medical or a behavioral health crisis for
the patient. Either a Network or non-Network ambulance provider may render 911
transportation without an authorization from WVFH.
WVFH also considers the following situations emergent, and thus does not require
authorization:
• ER-ER
• ER-to-Acute Care or Behavioral Health Facility
• Acute Cat-to-Acute Care or Behavioral health Facility
• Hospital-to-Hospital, when patient is being discharged from one hospital
and being admitted to another.
Providers should bill the above types of transports with the appropriate
emergency, basic life support code and the modifier HH.
Non-emergent
ambulance
transportation
Authorization for non-emergent ambulance transportation is required by
WVFH’s Utilization Management Department. WVFH considers non-emergent
transportation as transportation for a patient that does not require immediate
access to medical or behavioral healthcare and/or if not provided would not result
in a medical or a behavioral health crisis as non-emergent. Non-emergent
transportation may include the following scenarios:
• Ambulance transports from one facility to another when the member is
expected to remain at the receiving facility, which may include the
following:
 Hospital to Skilled Nursing Facility (SNF)
 SNF to Hospital (non-emergent)
 Hospital to Rehabilitation Facility
 Rehabilitation Facility to Hospital (non-emergent)
• Ambulance transport to home upon discharge (if medically necessary and
approved by WVFH)
A WVFH Network ambulance provider should be contacted to render nonemergent transportation when possible.
Continued on next page
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2.4 AMBULANCE SERVICES, Continued
Facility to
facility for
diagnostic
testing
Ambulance transportation from one facility to another for diagnostic testing or
services not available at the current facility, with the expectation of the member
returning to the original facility upon completion of service, is the responsibility of
the originating facility and does not require an authorization from WVFH. The
originating facility should assume the cost for this type of transport even if for
unforeseen circumstances, the member remains at the receiving facility. The
originating facility may contact any ambulance service of their choosing to
provide transport in this scenario only.
Wheelchair
van transport
All wheelchair van transportation requires an authorization from WVFH’s
Utilization Management Department.
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2.4 BILLING AND REIMBURSEMENT
Claims and
reimbursement
information
Please see this manual’s Chapter 3, Unit 2: Claims and Billing Information for
information regarding claims submission, and Chapter 3, Unit 3: Reimbursement
for information regarding reimbursement.
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CHAPTER 3: POLICIES AND PROCEDURES
UNIT 1: PRACTITIONER REQUIREMENTS AND GUIDELINES
IN THIS UNIT
TOPIC
General Information
• West Virginia DHHR/BMS Policy Changes
• Provider Manuals
• Practitioner Education and Sanctioning
• Practitioner Due Process
• Title VI of the Civil Rights Act of 1964
• Access and Interpreters for Members with Disabilities
• Provider Termination
Credentialing Practices
Confidentiality
Fraud and Abuse
Environmental Assessment Standards
Reporting of Required Reportable Diseases
NCQA Compliance Requirements
Marketing Policies and Practices
WEST VIRGINIA FAMILY HEALTH PROVIDER MANUAL | CHAPTER 3.1
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2
2
2
3
3
3
3
4
5
6
8
11
16
18
19
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3.1 GENERAL INFORMATION
Introduction
West Virginia Family Health (WVFH) has developed policies and procedures to
provide guidelines for identifying and resolving issues with practitioners who fail
to comply with the terms and conditions of the applicable Practitioner
Agreement, WVFH policies and procedures, or accepted Utilization Management
Standards and Quality Improvement Guidelines.
WV DHHR/BMS
policy changes
West Virginia Department of Health and Human Resources (DHHR), Bureau
of Medical Services (BMS) Policy Changes:
In order for WVFH to meet the standards set forth by the Bureau for Medical
Services (“BMS”) standard contract, WVFH must promptly implement new policies
or changes in policy at the request of BMS. Upon notice from BMS of program or
policy changes, WVFH will assess those policies or practices that require
practitioner notice.
Depending upon the BMS effective date of the change, practitioners cannot
always be notified prior to such alterations. WVFH is committed to notifying all
appropriate practitioners, via the most appropriate medium, within sixty (60) days
of receipt of the notice of a new policy or policy change when sufficient notice is
provided by BMS.
Additionally, practitioners need to be aware that no regulatory order or
requirement of the Departments of Insurance, Health and Human Services or
Bureau for Medical Services shall be subject to arbitration with WVFH.
Provider
manuals
This West Virginia Family Health Provider Manual and the Highmark Blue Shield
Office Manual are binding upon providers and may be supplemented or
superseded, in whole or in part, by other guidance and/or requirements furnished
or otherwise made available to providers, provided supplements do not conflict
with the applicable federal and state laws and regulations.
The Highmark Blue Shield Office Manual for professional providers is available on
the Highmark West Virginia Provider Resource Center under Administrative
Reference Materials. The Provider Resource Center is accessible from the
Highmark West Virginia website at www.highmarkbcbswv.com -- select the
Provider Resource Center link under HELPFUL LINKS.
Continued on next page
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3.1 GENERAL INFORMATION, Continued
Practitioner
education and
sanctioning
Network practitioners will be monitored for compliance with administrative
procedures, trends of inappropriate resource utilization, potential quality of care
concerns and compliance with medical record review standards. Practitioner
education is provided through Quality Improvement Nurses and Medical
Directors. Network practitioners who do not improve through the provider
education process will be referred to the Highmark West Virginia Quality
Improvement/Utilization Management Committee for evaluation and
recommendations. To request additional information or to obtain a copy of this
policy, please contact Provider Services.
WVFH encourages its providers to participate in training which promotes
sensitivity to the special needs of the West Virginia Medicaid population.
Practitioner
due process
WVFH has established a policy and procedure to define the situations when due
process procedures are afforded to practitioners, and to specify the due process
procedures available in accordance with federal and state regulations, in
particular the Healthcare Quality Improvement Act of 1986.
The Practitioner Due Process Policy will be updated in accordance with federal
and state regulations. To request additional information or to obtain a copy of this
policy, please contact Provider Services.
Title VI of the
Civil Rights Act
of 1964
Practitioners are expected to comply with Title VI of the Civil Rights Act of 1964
that prohibits race, color, or national origin discrimination in programs receiving
Federal funds. Practitioners are obligated to take reasonable steps to provide
meaningful access to services for members with limited English proficiency,
including provision of translator services as necessary for these members.
Access and
interpreters for
members with
disabilities
Practitioner offices are expected to address the need for interpreter services in
accordance with the Americans with Disabilities Act (ADA). Each practitioner is
expected to arrange and coordinate interpreter services to assist member who are
hearing impaired. WVFH will assist practitioners in locating resources upon
request. WVFH offers the Member Handbook and other WVFH information in large
print, Braille, on cassette tape, or computer diskette at no cost to the member.
Please instruct members to call Member Services at 1-855-412-8001 to ask for
these other formats.
Practitioner offices are required to adhere to the ADA guidelines, Section 504, the
Rehabilitation Act of 1973 and related federal and state requirements that are
enacted from time-to-time.
Continued on next page
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3.1 GENERAL INFORMATION, Continued
Provider
termination
For more information regarding corrective action, termination, and appeal
policies and procedures, please see Chapter 2, Unit 2: Network Credentialing
Procedures of the Highmark Blue Shield Office Manual.
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3.1 CREDENTIALING PRACTICES
Credentialing
nondiscrimination
practices
In selecting and credentialing providers for the associated networks, West Virginia
Family Health (WVFH) does not discriminate in terms of participation or
reimbursement, against any healthcare professional who is acting within the
scope of his or her license or certification under state law solely on the basis of the
license or certification. In addition, WVFH does not discriminate against
professionals who serve high-risk populations or who specialize in the treatment
of costly conditions.
For additional
credentialing
information
For additional information regarding credentialing and recredentialing for the
WVFH networks, please see the Highmark Blue Shield Office Manual’s Chapter 2,
Unit 2: Network Credentialing Procedures.
The Highmark Blue Shield Office Manual is available on the Highmark West Virginia
Provider Resource, which is accessible from Highmark Blue Cross Blue Shield West
Virginia website at www.highmarkbcbswv.com. The Provider Resource Center
link can be found under HELPFUL LINKS. The manual can be found by selecting
Administrative Reference Materials from the Resource Center’s main menu.
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3.1 CONFIDENTIALITY
Overview
All practitioners and providers participating with WVFH have agreed to abide by
all WVFH policies and procedures regarding member confidentiality. The
performance goal for confidentiality is maintaining patient records secure from
public access.
Member
confidentiality
policy
Under these policies, the practitioner or provider must meet the following:
1. Provide the highest level of protection and confidentiality of members’
medical and personal information used for any purposes in accordance
with federal and state laws or regulations including the following:
a. Health Insurance Portability and Accountability Act of 1996
(HIPAA), 45 CFR Parts 160, 162 and 164
b. Patient Protection and Affordable Care Act (PPACA), P.L. 111-148,
enacted on March 23, 2010, and the Health Care and Education
Reconciliation Act of 2010 (HCERA), P.L. 111-152, enacted on March
30, 2010
c. The Health Information Technology for Economic and Clinical
Health (HITECH) Act, Title XIII of Division A and Title IV of Division B
of the American Recovery and Reinvestment Act of 2009 (ARRA),
Pub.L.No. 111-5 (Feb 17, 2009) and related regulations.
d. 42 U.S.C. § 1396a(a)(7) – State plan for medical assistance
e. 42 C.F.R. § 431.300 et seq. – Medical Assistance – Safeguarding
Information on Applicants and Recipients
f. Section 29a of the West Virginia Code
2. Assure that member records, including information obtained for any
purpose, are considered privileged information and, therefore, are
protected by obligations of confidentiality.
3. Assure that a member’s individually identifiable health information as
defined by HIPAA, also known as Protected Health Information (PHI),
necessary for treatment, payment or healthcare operations (TPO) is
released to WVFH without seeking the consent of a member. This
information includes PHI used for claims payment, continuity and
coordination of care, accreditation surveys, medical record audits,
treatment, quality assessment and measurement, quality of care issues,
medical management, appeals, case management and disease
management. Further, providers will assure that PHI for TPO will be made
available to the WV Department of Health & Human Resources,
Department of Health, Department of Insurance or Business Associates of
WVFH for use without member consent. All other requests for release of or
access to PHI will be handled in accordance with federal and state
Continued on next page
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3.1 CONFIDENTIALITY, Continued
Member
confidentiality
policy
(continued)
regulations. WVFH follows the requirements of HIPAA and limits its
requests to the amount of PHI that is minimally necessary to meet the
treatment, payment, or operational function.
4. The member, or a member’s representative including head of household,
legal guardian, or durable power of attorney, shall have access to view
and/or receive copies of the medical record upon request. There is no
charge for the copied medical record if the record is sent to another
practitioner or provided directly to the member. The request must allow
reasonable notice and follow the specific procedures of the practitioner or
provider.
5. All providers are required to conduct environmental security of
confidential information and monitor practice and provider sites. Provider
and practitioner sites must comply with the Environmental Assessment
standards that require that patient records be protected from public
access.
6. Medical records must be available for all member visits for established
patients.
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3.1 FRAUD AND ABUSE
Overview
WVFH has a comprehensive policy for handling the prevention, detection, and
reporting of fraud and abuse. It is WVFH’s policy to investigate any action by
members, employees, or practitioners that affects the integrity of WVFH and/or the
Medicaid Program.
As a Network practitioner, the contract that is signed requires compliance with
WVFH’s policies and procedures for the detection and prevention of fraud and
abuse. Such compliance may include referral of information regarding suspected or
confirmed fraud or abuse to WVFH and submission of statistical and narrative
reports regarding fraud and abuse detection activities.
If fraud or abuse is suspected, whether it is by a member, employee, or practitioner,
it is your responsibility to immediately notify WVFH at 1-855-412-8004.
Recipient
Restriction
Program
WVFH maintains a Recipient Restriction Program, which restricts members who
misutilize medical services or pharmacy benefits. WVFH enforces and monitors
these restrictions through the following process:
• Identifying Members who are over utilizing and/or misutilizing medical
services.
• Evaluating the degree of abuse including review of pharmacy and medical
claims history, diagnoses and other documentation, as applicable.
• Proposing whether the Member should be restricted to obtaining services
from a single, designated Provider for a period of five years.
• Sending notification via certified mail to member of proposed restriction,
including reason for restriction, effective date and length of restriction,
name of designated provider(s) and option to change provider. Sending
notification of member’s restriction to the designated provider(s).
• Enforcing the restrictions through appropriate notifications and edits in the
claims payment system.
• Monitoring subsequent utilization to ensure compliance.
• Changing the selected provider per the member’s or provider’s request,
within thirty (30) days from the date of the request.
• Reviewing the member’s services prior to the end of the five-year period of
restriction to determine if the restriction should be removed or maintained,
with notification of the results of the review to BMS, member, provider(s)
and CAO.
• Educating members including explanations in handbooks.
Continued on next page
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3.1 FRAUD AND ABUSE, Continued
Investigating
fraud and
abuse
It is WVFH’s policy to discharge any employee, terminate any practitioner, or
recommend any member be withdrawn from the Medicaid Program who, upon
investigation and referral to the Department of Health and Human Resources, has
been identified as being involved in fraudulent or abusive activities.
The Department of Health and Human Resources has an established Office of
Quality and Program Integrity (OQPI) that is charged with investigating
complaints and identifying potential fraud, waste, and abuse occurring within the
Medicaid system. Complaints are received from various sources for development,
investigation, and appropriate resolution.
WVFH works in conjunction with OQPI refer cases and investigate cases to
determine if there is a credible allegation of fraud, waste, or abuse. If it is a
credible allegation of fraud, waste, or abuse, the complaint is referred to the West
Virginia Office of the Inspector General Medicaid Fraud Control Unit (MFCU).
MFCU has jurisdiction under federal and state law to investigate West Virginia
Medicaid providers for potential fraudulent practices, and the authority to seek
criminal and civil remedies when fraudulent practices are discovered.
Examples
of fraud
and abuse
Some common examples of fraud and abuse are:
• Billing or charging Medicaid recipients for covered services
• Billing for services not rendered
• Billing for separately for services in lieu of an available combination code
• Billing more than once for the same service
• Dispensing generic drugs and billing for brand name drugs
• Falsifying records
• Performing inappropriate or unnecessary services
Reporting
fraud
Complaints regarding member fraud should be referred to the West Virginia
Office of the Inspector General Investigations and Fraud Management Unit.
If Medicaid Fraud is suspected, you must contact the Medicaid Fraud Control Unit
at: 1-888-FRAUDWV (1-888-372-8398); or 1-304-558-1970.
Complete the online reporting form at: https://www.wvdhhr.org/oig/mfcu.html
Continued on next page
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3.1 FRAUD AND ABUSE, Continued
Reporting
fraud
(continued)
Or submit in writing to:
False Claims
Act
Regarding False Claims Acts, pursuant to Section 6032 of the Deficit Reduction Act
of 2005, any entity who receives or makes Title XIX (Medicaid) payments of at least
$5,000,000 annually must establish written or electronic policies and procedures
for the education of employees of affected entities regarding false claims
recoveries.
Department of Health and Human Resources
Investigations and Fraud Management
Office of Inspector General
1900 Kanawha Boulevard, East
Capitol Complex, Building 6, Room B-817
Charleston, WV 25305
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3.1 ENVIRONMENTAL ASSESSMENT STANDARDS
Overview
WVFH has established specific guidelines for conducting Environmental
Assessment Site Visits, including medical record-keeping standards at PCP,
OB/GYN, and other high volume specialty practices. An initial Environmental
Assessment will be conducted at all PCP, OB/GYN, and other high volume
specialty office sites as part of the credentialing process. The purpose of the site
visit is to assure that practitioners are in compliance with WVFH’s Environmental
Assessment Standards.
On-site
visits
A Provider Relations Representative will schedule an on-site visit at each office site
to conduct an Environmental Assessment. The Environmental Assessment must
be conducted with the Office Manager or with a practitioner of the practice. The
Provider Relations Representative will complete the Initial Environmental
Assessment Form and tour the office as well as interview staff and examine the
appointment schedule. The Provider Relations Representative will assess the
office for evidence of compliance with the Environmental Assessment Standards.
The Provider Relations Representative will conduct a follow-up visit within 90 days
or until the office site is compliant. The Medical Director will review the
Environmental Assessment as part of the initial credentialing process. If any of the
standards are not met, the Medical Director will assess the potential impact of the
discrepancy to patient care and evaluate the corrective action plan. If the plan is
reasonable, the practitioner will continue with the credentialing process. If the
plan is not acceptable, the Medical Director may suggest a different corrective
action plan or delay the credentialing process until the issue is resolved. If the
office is not agreeable to correcting the identified problem, the information will
be presented to the Quality Improvement/Utilization Management Committee for
review. Special circumstances may be granted based upon size, geographic
location of the practice, and potential harm to members. The Provider Relations
Representative will communicate the final results to the practitioners.
An Environmental Assessment will not be conducted if a new practitioner joins an
office site or if the practitioner relocates to an office that has already been
reviewed and meets WVFH standards. When credentialing a new practitioner who
joins an existing office site, the documentation from that site visit for that office
will be included in the new practitioner’s initial credentialing file prior to the
Quality Improvement/Utilization Management Committee review. Site visits for
relocated offices must be conducted prior to the practitioner’s recredentialing
date. The documentation of that site visit will be included in the recredentialing
file.
Continued on next page
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3.1 ENVIRONMENTAL ASSESSMENT STANDARDS, Continued
On-site
Visits
(continued)
Provider Relations Representatives conduct site visits to assess practice
compliance with the Americans with Disabilities Act and Section 504 of the
Rehabilitation Act of 1973 for those practices as determined by the Department of
Health & Human Resources.
PRACTITIONER OFFICE SITE QUALITY EVALUATION
MET
NOT MET
N/A
COMMENTS
1. The office is reasonably accessible (noting the
ease of entry into and the accessibility of space
within the building) for patients with physical
and/or sensory disabilities. (ALL)
2. The physical appearance of the office is clean,
organized and well maintained for the safely of
patients, staff and visitors. (ALL)
3. The waiting area is well lit, has adequate space and
seating, and has posted office hours. (ALL)
4. There is adequacy of examining/treatment room
space as well as patient interview areas and each
are designed to respect patients' dignity and
privacy. (ALL)
5. Clinical records are filed in an organized,
systematic manner, easily located, and kept in a
secure, confidential location and away from
patient access. Only authorized persons have
access to clinical records. (ALL)
6. The office has a written confidentiality policy to
avoid the unauthorized release or disclosure of
confidential personal health information including
but not limited to computer screens, data disks, emails, telephone messages/calls fax machines.
(ALL)
7. The medical equipment utilized in the office
appears to be adequate, well maintained, up to
date, appropriate for the patients' age and
appropriate for the specialty of the practice.
(ALL)
8. The office has 24-hour medical coverage that is
available seven (7) days a week. (ALL)
9. The office has a process to ensure after-hours
calls are returned within 30 minutes. (ALL)
10. The office has a process to ensure after-hours
calls are communicated to the office by the
morning of the following business day. (ALL)
Continued on next page
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3.1 ENVIRONMENTAL ASSESSMENT STANDARDS, Continued
MET
NOT MET
N/A
COMMENTS
11. The office has mechanisms to assess behavioral
health disorders, alcohol and other drug
dependence (i.e., screening tool or
questionnaire). (PCP, OBGYN)
12. No more than six (6) office visits are scheduled
per hour, per practitioner. (ALL)
13. Emergency, life-threatening, medical situations
are handled immediately. (ALL EXCEPT BH)
14. Urgent medical care appointments, which
require rapid clinical intervention as a result of
an unforeseen illness, injury, or condition, are
available within 1 day (e.g., high fever, persistent
vomiting/diarrhea). (PCP, SPECIALIST)
15. Regular and routine care appointments that are
non-urgent but in need of attention are available
within 2-7 days (e.g., headache, cold, cough,
rash, joint/muscle pain, etc.). (PCP, SPECIALIST)
16. Regular and routine care appointments for
routine wellness appointments are available
within 30 days (e.g., symptomatic preventive
care, well child/patient exams, physical exams,
etc.). (PCP, SPECIALIST)
17. Patients with chronic conditions (e.g., diabetes,
hypertension, CHF, depression, etc.) are
proactively notified by the office and
encouraged to schedule an appointment. (PCP)
18. There is a process to assure that patients who
either no show or cancel their appointments are
contacted & encouraged to reschedule the
appointments as evidenced by documentation
of such in the medical record (appointment
scheduled, reminder card, etc.). (PCP)
19. A reminder call is made by the practice prior to
scheduled appointments to encourage
attendance with the scheduled visit. (PCP)
20. There is a process confirming that laboratory,
diagnostic procedure, and/or consultation
appointments were performed and results were
received, reviewed, and filed in the patient's
medical record. The process:
a) Identifies how the laboratory, diagnostic
procedures and/or consultation
appointments are tracked
b) Identifies staff responsible to ensure results
are returned to the office
Continued on next page
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3.1 ENVIRONMENTAL ASSESSMENT STANDARDS, Continued
MET
21.
22.
23.
24.
25.
26.
27.
28.
NOT MET
N/A
COMMENTS
c) Identifies when and how staff match test
results with patient's chart d) Identifies how
the reviewer (practitioner) notifies how the
results should be handled. (PCP)
There is a process in place to ensure patients are
notified of abnormal results. (ALL)
Urgent medical care appointments which require
rapid clinical intervention as a result of an
unforeseen illness, injury, or condition are
available within 1 day such as:
a) OB: High fever, persistent vomiting /
diarrhea, bladder infection, increased
swelling.
b) GYN: Unusual vaginal discharge or vaginal
bleeding post-menopause/hysterectomy, or
detection of breast mass/breast lump.
(OBGYN)
Regular and routine care appointments that are
non-urgent but in need of attention are available
within 2-7 days:
a) OB: Small amount of swelling in ankles or
hands, sciatica pain (including hip/leg pain),
respiratory infection, UTI symptoms
b) GYN: Increased menstrual cramps. (OBGYN)
Regular and routine care appointments for
routine wellness appointments are available
within 30 days (e.g., regular routine obstetrical
and gynecological appointments). (OBGYN)
Immediate intervention for a life-threatening
emergency is required to prevent death or
serious harm to patient or others. (BH)
Intervention within 6 hours is required for a nonlife-threatening emergency to prevent acute
deterioration of the patient's clinical state that
compromises patient safety. (BH)
Timely evaluation (within 48 hours) is needed for
urgent care to prevent deterioration of the
patient’s condition. (BH)
Routine office visits are available (within 10
business days) when the patient's condition is
considered to be stable. (BH)
Continued on next page
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3.1 ENVIRONMENTAL ASSESSMENT STANDARDS, Continued
MET
NOT MET
N/A
COMMENTS
1. An individual clinical record is established,
organized, easily located and data is easily
retrievable for each patient. (ALL)
2. Each page in the medical record contains the
patient's name. Another form of patient
identification (e.g., birth date, social security
number, identification number, etc.) is
documented on the medical record. (ALL)
3. Significant illnesses and medical and behavioral
health conditions are indicated on the current
problem list and are updated after each office
visit and hospitalization. (ALL)
4. Each record indicates which medications have
been prescribed, the dosages of each, the date of
the initial prescription and/or refill, and the date
the medication was discontinued, as applicable.
(ALL)
5. Medication & other allergies, adverse reactions, &
relevant medical conditions are clearly
documented and dated prominently in the
record. It is noted if the patient has no known
allergies, no history of adverse reactions or
relevant medical conditions. (ALL)
6. All entries in the record contain a valid, legible
author's signature, which may be a handwritten
signature with credentials, printed name &
credentials accompanied by handwritten
provider initials, or unique electronic identifier
with credentials. (ALL)
7. All entries in the record are dated and are legible
to someone other than the writer. (ALL)
8. The medical/treatment records have a notation
regarding follow-up care, calls or visits, when
indicated. The specific time of return is noted in
weeks, months, or as needed. (ALL)
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3.1 REPORTING OF REQUIRED REPORTABLE DISEASES
Overview
Health care providers are required to report certain diseases by state law. This is to
allow for both disease surveillance and appropriate case investigation/public
follow-up. WVFH may be responsible for:
1) Further screening, diagnosis, and treatment of identified cases enrolled in
WVFH as necessary to protect the public’s health; or
2) Screening, diagnosis, and treatment of case contacts who are enrolled in
WVFH.
Detailed infectious disease reporting requirements can be obtained from the
Bureau for Public Health within the Department of Health and Human Resources.
Primary types
of diseases
that must be
reported
The three primary types of diseases that must be reported are:
1. Division of Surveillance and Disease Control, Sexually Transmitted
Disease Program. Sexually transmitted diseases (STDs) are required to be
reported for disease surveillance purposes and for appropriate case
investigation and follow-up. For contact notification, WVFH must refer case
information to the Division of Surveillance and Disease Control. The
Division has an established program for notifying partners of persons with
infectious conditions. This includes follow-up of contacts to individuals
with HIV and AIDS. Once notified, contacts who are enrollees of WVFH may
be referred back to WVFH for appropriate screening and treatment, if
necessary.
2. Division of Surveillance and Disease Control, Tuberculosis Program.
Individuals with diseases caused by M. tuberculosis must be reported to
the WV Bureau for Public Health, DSDC, TB Program for appropriate
identification, screening, treatment and treatment monitoring of their
contacts.
3. Division of Surveillance and Disease Control, Communicable Disease
Program. Cases of communicable disease noted as reportable in West
Virginia must be reported to the local health departments in the
appropriate time frame and method outlined in legislative rules. This both
provides for disease surveillance and allows appropriate public health
action to be undertaken—patient education and instruction to prevent
further spread, contact identification and treatment, environmental
investigation, outbreak identification and investigation, etc. (Note: Per
legislative rule, reports of category IV diseases [including HIV and AIDS] are
submitted directly to the state health department, not to local
jurisdictions.)
Continued on next page
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3.1 REPORTING OF REQUIRED REPORTABLE DISEASES, Continued
Federal
reporting
requirements
In order to assist WVFH with its obligations to comply with the following Federal
reporting and compliance requirements for the services listed below, providers
are required to comply with the following federal reporting requirements:
• Abortions must comply with the requirements of 42 CFR 441. Subpart E –
Abortions. This includes completion of the information form, Certification
Regarding Abortion. For more information, see Chapter 2, Unit 3: OB/GYN
Services of this manual (page 9).
• Hysterectomies and sterilizations must comply with 42 CFR 441. Subpart F
– Sterilizations. This includes completion of the consent form. For more
information, see Chapter 2, Unit 3: OB/GYN Services of this manual (page 8).
• EPSDT services and reporting must comply with 42 CFR 441 Subpart B –
Early and Periodic Screening, Diagnosis, and Treatment. For more
information, see this manual’s Chapter 1, Unit 3: Growing Up Program .
Other
reporting
requirements
The data that must be certified include, but are not limited to, enrollment
information, encounter data, and other information required by the State of West
Virginia and contained in contracts, proposals, and related documents. Additional
reporting elements include: provider network, utilization, quality, access, EPSDT,
financial data, member satisfaction, HEDIS scores, and number and types of
informal and formal grievances and appeals registered by enrollees and providers.
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3.1 NCQA COMPLIANCE REQUIREMENTS
Compliance
with NCQA
accreditation
standards
Providers acknowledge and agree that certain provisions are required to be in
contracts between West Virginia Family Health and providers for compliance with
the accreditation standards of the National Committee for Quality Assurance
(NCQA). Pursuant to such NCQA compliance requirements, providers agree to
acknowledge and cooperate with West Virginia Family Health’s quality initiative
activities.
West Virginia Family Health may utilize provider performance data for activities
including, but not limited to, quality improvement activities, public reporting to
consumers, transparency activities, and/or any other activity of or relating to West
Virginia Family Health compliance with the accreditation standards of the NCQA.
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3.1 MARKETING POLICIES AND PRACTICES
Approved
marketing
practices
The list of approved Marketing practices is not intended to be exhaustive. The
following list is applicable to WVFH (acting as an Managed Care Organization
[MCO] in the State of West Virginia), its agents, subcontractors, and WVFH
providers:
1. The MCO is allowed to send outreach materials and non-Marketing
correspondence to its members. The content of such mailings must be
approved by the Bureau of Medical Services (BMS) prior to distribution.
2. Terms such as “choose,” “pick,” “join,” etc. are allowed in marketing
materials as long as the Enrollment Broker contractor’s telephone number is
included.
3. WVFH may send plan specific materials to potential members at the
potential member’s request. The content of such mailings must be
approved by BMS prior to distribution.
4. WVFH may only provide plan specific information during incoming calls
from potential members. WVFH may return telephone calls to potential
members only when requested to do so by the caller. The content of such
call scripts must be approved by BMS prior to distribution.
5. WVFH may respond to direct questions from potential members with
accurate information during such telephone calls.
6. WVFH may survey their former and currently enrolled members.
7. WVFH may provide gifts approved by BMS to encourage currently enrolled
members to participate in the surveys.
8. WVFH may distribute materials and information that purely educate its
members on the importance of completing the State’s Medicaid eligibility
renewal process in a timely fashion.
9. At BMS’s approval, WVFH may provide information about a Qualified Health
Plan (QHP) to potential members who could enroll in such a plan as an
alternative to the Medicaid managed care plan due to a loss of Medicaid
eligibility or to potential members who may consider the benefits of
selecting an Medicaid managed care plan that has a related QHP in the
event of future eligibility changes. Such information may not be included
within marketing materials.
Prohibited
practices
The following policies and practices are prohibited and violate the State BMS
contract. This list is not intended to be exhaustive. The following prohibitions are
applicable to WVFH, its agents, subcontractors, and WVFH providers:
1. Distributing Marketing materials without prior BMS approval;
2. Using the word, “Mountain,” or phrase, “Mountain Health,” “Health Bridge,”
except when referring to Mountain Health Trust, West Virginia Health
Bridge, or other State programs;
Continued on next page
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3.1 MARKETING POLICIES AND PRACTICES, Continued
Prohibited
practices
(continued)
3. Distributing Marketing materials written above the 6th grade reading level,
unless approved by BMS;
4. Offering gifts valued over $15.00 to potential members;
5. Providing gifts to providers for the purpose of distributing them directly to
WVFH’s potential members or currently enrolled members;
6. Directly or indirectly, engaging in door-to-door, telephone, and other Cold
Call Marketing activities;
7. Marketing in or around public assistance offices, including eligibility offices;
8. Using “Spam;”
9. Making any assertion or statement (orally or in writing) that WVFH is
endorsed by CMS, a federal or state government agency, or similar entity;
10. Knowingly marketing to persons currently enrolled in another MCO;
11. Inducing or accepting a member’s MCO enrollment or MCO disenrollment;
12. Using terms that would influence, mislead, or cause potential members to
contact WVFH, rather than the Enrollment Broker, for enrollment;
13. Portraying competitors in a negative manner;
14. Using absolute superlatives (e.g., “the best,” “highest ranked,” “rated
number 1”) unless they are substantiated with supporting data provided to
BMS;
15. Making any written or oral statements containing material
misrepresentations of fact or law relating to WVFH’s plan or the Medicaid
program, services, or benefits;
16. Making potential member gifts conditional based on enrollment with
WVFH;
17. Charging members for goods or services distributed at WVFH or Medicaid
events;
18. Charging members a fee for accessing the WVFH’s website;
19. Influencing enrollment in conjunction with the sale or offering of any
private insurance;
20. Tying enrollment in WVFH with purchasing (or the provision of) other types
of private insurance;
21. Using marketing agents who are paid solely by commission;
22. Posting WVFH-specific, non-health related materials or banners in provider
offices;
23. Conducting potential member orientation in common areas of providers’
offices;
Continued on next page
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3.1 MARKETING POLICIES AND PRACTICES, Continued
Prohibited
practices
(continued)
24. Allowing providers to solicit enrollment or disenrollment in WVFH, or
distribute WVFH-specific materials at a Marketing activity (this does not
apply to health fairs where providers do immunizations, blood pressure
checks, etc. as long as the provider is not soliciting enrollment or
distributing plan specific MCO materials);
25. Making charitable contributions or donations from Medicaid funds;
26. Purchasing or otherwise acquiring mailing lists from third party vendors, or
for paying BMS’s contractors or subcontractors to send plan specific
materials to potential members;
27. Referencing the commercial component of WVFH in any Marketing
materials;
28. Discriminating against a member or potential member because of race, age,
color, religion, natural origin, ancestry, marital status, sexual orientation,
physical or mental disability, health status or existing need for medical care,
with the following exception: certain gifts and services may be made
available to members with certain diagnoses;
29. Assisting with Medicaid MCO enrollment form;
30. Making false, misleading or inaccurate statements relating to services or
benefits of WVFH or Medicaid program, or relating to the providers or
potential providers contracting with WVFH; and
31. Direct Mail Marketing to potential members.
Gifts to
potential
members
WVFH may provide promotional gifts valued at or under $15 to potential WVFH
members. WVFH may distribute promotional gifts valued at more than $15 to
current members only. A gift worth $15 or less must be based on the retail
purchase price of the gift item. WVFH may not provide gifts to providers for the
purpose of distributing them potential members, unless such gifts are placed in
the providers’ office common areas and are available to all patients.
MCO member
gifts
WVFH may solicit its currently enrolled members for participation in WVFH
activities.
WVFH may provide gifts valued at $50.00 or less per member per gift to
encourage member attendance or participation in WVFH activities. Member gifts
may not be converted to cash. WVFH must not exceed the total annual limit of
$150.00 per each member for all gifts.
BMS must provide prior approval of all monetary and non-monetary
compensation provided to members in exchange for participating in WVFH
activities.
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CHAPTER 3: POLICIES AND PROCEDURES
UNIT 2: CLAIMS AND BILLING INFORMATION
IN THIS UNIT
TOPIC
SEE PAGE
Member Billing Policy
Excluded Providers or Credible Allegation of Provider Fraud
Claims Submission
Timely Filing
Prompt Pay
• Payment Time Frames
• BMS Reimbursement Hold Harmless
Electronic Claims Submission
Electronic Remittance Advice (ERA)
Claims Review
• Administrative Claims Review
• Medical Claims Review
Coordination of Benefits
• Coordination of Benefits Policy
• Specialty/Fee-For-Service Providers
• Medicare
• Nursing Care
• Subrogation
Primary Care Services
Claim Coding Software
Billing
Early and Periodic Screening, Diagnostic, and Treatment
(EPSDT) Services
• EPSDT Claim Submission Time Frame
• FQHC/RHC Billing
• 1500 Paper Format Requirements
• 1500 EDI Format Requirements
Obstetrical Care Services
Hospital Services
UB-04 Data Elements for Claims Submission
Sample UB-04 Claim Form
1500 Data Elements for Claims Submission
Sample 1500 Claim Form
2
3
4
6
7
7
7
8
11
12
12
13
14
14
15
16
17
17
19
21
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24
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3.2 MEMBER BILLING POLICY
Policy
Payment by West Virginia Family Health (WVFH) is considered payment in
full. Under no circumstance, including but not limited to non-payment by
WVFH for approved services, may a provider bill, charge, collect a deposit
from, seek compensation, remuneration, or reimbursement from or have any
recourse against a WVFH member.
This provision shall not prohibit collection of copayments on WVFH’s behalf made
in accordance with the terms of the MCO Provider Agreement between WVFH and
the Department of Health and Human Resources, Bureau for Medical Services.
Providers may not collect copays from a WVFH member for missed appointments.
Practitioners may directly bill Members for non-covered services or services
rendered to the member that exceeds coverage or service limitations provided,
however, that prior to the provision of such non-covered services, the practitioner
must inform the Member in writing and have the member acknowledge receipt in
writing:
(i) of the service(s) to be provided;
(ii) that WVFH will not pay for or be liable for said services;
(iii) of the Member’s rights to appeal an adverse coverage decision as fully set
forth in the Provider Manual; and
(iv) absent a successful appeal, that Member will be financially liable for such
services.
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3.2 EXCLUDED PROVIDERS OR CREDIBLE ALLEGATION OF
PROVIDER FRAUD
Excluded
providers
In accordance with 42 CFR 1001.1901(c)(5), payment under Medicaid is not
available for excluded providers except for emergency medical services or items.
To be payable, a claim for such emergency items or services must be
accompanied by a sworn statement of the person furnishing the items or services
specifying the nature of the emergency and why the items or services could not
have been furnished by an individual or entity eligible to furnish or order such
items or services. No claim for emergency items or services will be payable if such
items or services were provided by an excluded provider who, through an
employment, contractual, or any other arrangement, routinely provides
emergency health care items or services.
Credible
allegation
of fraud
42 CFR 455.23 requires State Medicaid Agency to suspend all Medicaid payments
to a provider after the Agency determines there is a credible allegation of fraud for
which an investigation is pending under the Medicaid program against an
individual or entity unless the agency has good cause not to suspend payments or
suspend payment only in part. The rules governing payment suspensions based
upon pending investigations of credible allegations of fraud apply to Medicaid
managed care entities.
WVFH is required to cooperate with BMS when payment suspensions are imposed
for the Medicaid provider by BMS. Upon receipt of the BMS notice for payment
suspension, WVFH will be required to suspend payments to the provider within
one (1) business day.
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3.2 CLAIMS SUBMISSION
Electronic
claim
submission
encouraged
WVFH encourages providers to utilize electronic claim billing (see the Electronic
Claims Submission section in this unit). When electronic claims submission is not
possible, please see the claim filing requirements in the Billing section of this unit.
Mail paper copies to the following address:
West Virginia Family Health
Claims Department
P.O. Box 830499
Birmingham, AL 35283
Telephone: 1-855-412-8002
General
information
Claim submission procedures for WVFH are as follows:
• All drug-specific claim information reported to WVFH using the 837P
format and the 837 I format MUST be reported with a HCPCS code, such as
a J-Code, and an NDC code. Claims submitted without both the
appropriate HCPCS Code and NDC will be rejected by Emdeon.
• Submit claims for all services provided.
• Payment for CPT and HCPCS codes are covered to the extent that they are
recognized by Medicaid or allowed per medical review determination by
WVFH. Correct coding (procedure, diagnosis, HCPCS) must be submitted
for each service rendered. WVFH utilizes CMS place of service codes to
process claims, and they are the only place of service codes that are
accepted.
• WVFH does accept bills through electronic data interchange (EDI) and
encourages facilities and providers to submit claims via this format.
• Correct/current practitioner information, including WVFH Provider ID
Number, must be entered on all claims. The format is 7 digits.
• Correct/current member information, including WVFH Member ID Number,
must be entered on all claims. The format is 8 digits.
• Please allow four to six weeks for a remittance advice. It is the practitioner’s
responsibility to research the status of a claim.
• Timely filing criteria for initial bills are 12 months from the date of service
or payment by the primary carrier. Corrected claims or requests for review
are considered if information is received within the 180 day follow-up
period from the date on the remittance advice.
Continued on next page
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3.2 CLAIMS SUBMISSION, Continued
General
information
(continued)
•
WVFH is the payer of last resort when any commercial or Medicare plan
covers the member. WVFH is obligated to process claims involving auto
insurance or casualty services as the primary payer if bills do not include a
notation or payment by any insurance that is not a commercial or
Medicare plan and WVFH will pursue recovery from the other carrier.
Claims must be submitted within WVFH’s timely filing guidelines.
•
Any reimbursement or coding changes made by BMS to its current
inpatient and outpatient fee schedules shall be implemented by WVFH
the month BMS notifies WVFH of such change. There will be no
adjustments made to previously processed claims due to any retroactive
change implemented by BMS.
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3.2 TIMELY FILING
Policy
Practitioners must submit a complete original industry standard claim form within
365 calendar days after the date of service or the date a primary payer paid or
denied the claim.
Paper claims
If you bill on paper, WVFH will only accept paper claims on a 1500 Form or a UB-04
Form (or their replacements). No other billing forms will be accepted. Paper claims
that are not received on original forms with red ink may delay final processing as
original forms are required for every claim submission.
EPSDT and
primary care
services
All EPSDT claims and primary care services should be submitted within 60
calendar days from the date of service to permit accurate member outreach.
Claim
inquiries
Any claim that has been submitted to WVFH but does not appear on a remittance
advice within sixty (60) days following submission should be researched by the
practitioner. Call the WVFH Provider Services Department at 1-855-412-8002 to
inquire whether the claim was received and/or processed.
Exceptions to
timely filing
Exceptions to timely filing criteria are evaluated upon receipt of documentation
supporting the request for the exception. Upon approval, exceptions are granted
on a one-time basis, and the claim system is noted accordingly.
WVFH
secondary
Practitioners must bill within 12 months from the date of an EOB from the primary
carrier when WVFH is secondary. An original bill along with a copy of the EOB is
required to process the claim. Requests for reviews/corrections of processed
claims must be submitted within 180 days from the date of the corresponding
remittance advice.
All claims submitted after the 12-month period for initial claims or after the 180
day follow-up period from the date on the remittance will be denied.
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3.2 PROMPT PAY
Definitions
A claim is defined as a bill for services, a line item of service, or all services for one
recipient within a bill.
A clean claim is defined as one that can be processed without obtaining
additional information from the provider of the service or from a third party. It
does not include a claim from a provider who is under investigation for fraud or
abuse, or a claim under review for medical necessity.
Payment
time frames
WVFH agrees to make timely claims payments to both its contracted and
non-contracted providers. WVFH shall pay all in-network provider Clean Claims
from subcontractors, which shall include Provider, for Covered Services within
thirty (30) calendar days of receipt, except to the extent subcontractors or
Provider have agreed to later payment in writing.
WVFH shall pay all electronic out-of-network clean claims within 30 days and all
paper out-of-network clean claims within 40 days from the date of receipt, except
to the extent the provider has agreed to later payment in writing.
WVFH agrees to specify the date of receipt as the date WVFH receives the claim, as
indicated by its date stamp on the claim, and date of payment as the date of the
check release or other form of payment release to the provider.
WVFH pays in-network providers interest at 7% per annum, calculated daily for
the full period in which the clean claim remains unpaid beyond the 30-day clean
claims payment deadline. Interest owed to the provider must be paid on the same
date as the claim.
MCO shall pay all other claims, except those from providers under investigation
for fraud and abuse, within twelve (12) months of the date of receipt.
BMS
Reimbursement
Hold Harmless
The Bureau of Medical Services (BMS) is not liable or responsible for payment of
covered services rendered to Members pursuant to provider agreement.
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3.2 ELECTRONIC CLAIMS SUBMISSION
Overview
WVFH can accept claims electronically through Emdeon or RelayHealth. WVFH
encourages practitioners to take advantage of our electronic claims processing
capabilities. Submitting claims electronically offers the following benefits:
• Faster Claims Submission and Processing
• Reduced Paperwork
• Increased Claims Accuracy
• Time and Cost Savings
Payer IDs
For submission of professional or institutional electronic claims for WVFH, please
refer to the following grid for Emdeon Payer IDs and RelayHealth CPIDs
(Clearinghouse Process ID):
Requirements
for submitting
claims through
Emdeon and
RelayHealth
CPID
PAYER NAME
PAYER ID
CLAIM TYPE
45276
45276
West Virginia Family Health (WVFH)
West Virginia Family Health (WVFH)
45276
45276
Professional
Institutional
To submit claims to WVFH please note the Payer ID Number is 45276.
WVFH has a health plan specific edit through Emdeon and RelayHealth for
electronic claims that differ from the standard electronic submission format
criteria. The edit requires a WVFH assigned 8-digit member identification number,
the member number field allows 8 or 11 digits to be entered. For practitioners
who do not know the member’s WVFH identification number, it is acceptable to
submit the member’s Medicaid Recipient Number on electronic claims.
In addition to edits that may be received from Emdeon and RelayHealth, WVFH
has a second level of edits that apply to procedure codes and diagnosis codes.
Claims can be successfully transmitted to Emdeon and RelayHealth, but if the
codes are not currently valid they will be rejected by WVFH.
Practitioners must be diligent in reviewing all acceptance/rejection reports to
identify claims that may not have successfully been accepted by Emdeon,
RelayHealth, and WVFH. Edits applied when claims are received by WVFH will
appear on an EDI Report within the initial acceptance report or Claims
Acknowledgment Report. A claim can be rejected if it does not include an NPI and
current procedure and diagnosis codes.
Continued on next page
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3.2 ELECTRONIC CLAIMS SUBMISSION, Continued
Requirements
for submitting
claims through
Emdeon and
RelayHealth
(continued)
To assure that claims have been accepted via EDI, practitioners should receive and
review the following reports on a daily basis:
• Emdeon -- Provider Daily Statistics (RO22)
• Emdeon -- Daily Acceptance Report by Provider (RO26)
• Emdeon -- Unprocessed Claim Report (RO59)
• RelayHealth – Claims Acknowledgment Report (CPI 651.01)
• RelayHealth – Exclusion Report (CPI 652.01)
• RelayHealth – Claims Status Report (CPA 425.02)
If you are not submitting claims electronically, please contact your EDI vendor for
information on how you can submit claims electronically. You may also call
Emdeon directly at 1-877-469-3263 or RelayHealth at 1-800-545-2488.
WVFH will accept electronic claims for services that would be submitted on a
standard 1500 Form (02/12) or a UB-04 Form, or other successor form. However,
the following cannot be submitted as attachments along with electronic claims at
this time:
• Claims with EOBs
• Services billed by report
• The PCP Referral Form (paper version)
HIPAA 5010
and ICD-10
strategy and
timeline
The 5010 version of the HIPAA electronic transactions is required in order to
support the transfer of ICD-10 diagnosis code and ICD-10 procedure code data on
claims and remittances.
Effective January 1, 2012, only version 5010 transactions will be accepted. The
billing provider address submitted on claims must be a physical address. Claims
submitted via Emdeon or RelayHealth will be rejected if a P.O. Box number is
submitted as the billing address. In order to prevent claims from being rejected,
please be sure to submit a physical address as the billing address.
October 1, 2015 -- Compliance date for implementation of ICD-10-CM
(diagnoses) and ICD-10-PCS (procedures):
• ICD-9-CM codes will not be accepted for services provided on or after
October 1, 2015
• ICD-10 codes will not be accepted for services prior to October 1, 2015
• Providers must begin using the ICD-10-CM codes to report diagnoses from
all ambulatory and physician services on all paper and electronic claims
with dates of service on or after October 1, 2015, and for all diagnoses on
Continued on next page
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3.2 ELECTRONIC CLAIMS SUBMISSION, Continued
HIPAA 5010
and ICD-10
strategy and
timeline
(continued)
all paper and electronic claims for inpatient settings with dates of
discharge that occur on or after October 1, 2015.
• Additionally, hospitals must begin using the ICD-10-PCS (procedure codes)
for all hospital claims for inpatient procedures on paper and electronic
claims with dates of discharge that occur on or after October 1, 2015.
For more information on this topic, please see Chapter 5, Unit 2: Claims
Submission and Billing Information of the Highmark Blue Shield Office Manual.
The Highmark Blue Shield Office Manual for professional providers is available on
the Highmark West Virginia Provider Resource Center under Administrative
Reference Materials. The Provider Resource Center is accessible from the
Highmark West Virginia website at https://www.highmarkbcbswv.com/home/ -select the Provider Resource Center link under HELPFUL LINKS.
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3.2 ELECTRONIC REMITTANCE ADVICE (ERA)
ERA
overview
Providers may receive electronic claims remittance advice (ERA). WVFH uses
Emdeon to transfer the 835 Version 5010A Healthcare Claim Remittance Advice to
claim submitters. Rules for format, content, and field values can be found in the
Implementation Guides available on the Washington Publishing Company’s
website at www.wpc-edi.com.
Due to the evolving nature of HIPAA regulations, these documents are subject to
change. Substantial effort has been taken to minimize conflicts or errors.
There is a distinct data variation between the paper WVFH Claims Remittance
Advice and the 835 Transaction. The difference occurs in the code sets that tell
claim submitters the results of each claim’s adjudication. Few WVFH and HIPAA
Adjustment Reason Codes have solid, unambiguous matches at the same level of
detail. A crosswalk has been created in attempt to ease the code set transition and
can be located on WVFH’s website at www.wvfh.com.
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3.2 CLAIMS REVIEW
Claims
review
process
WVFH will review any claim that a practitioner feels was denied or paid incorrectly.
The request may be conveyed in writing or verbally through WVFH’s Provider
Services Department if the inquiry relates to an administrative issue. Please
forward all the appropriate documentation, i.e. the actual claim, medical records,
and notations regarding telephone conversations, in order to expedite the review
process. Initial claims that are not received within the 12 month timely filing limit
will not qualify for review. All follow-up review requests must be received within
180 calendar days of the initial remittance advice.
WVFH cannot accept verbal requests to retract claim(s) overpayments. Providers
may complete and submit a Refund Form, which is also located in this manual’s
Appendix, or write a letter that contains all of the information requested on the
Refund Form along with your check to:
West Virginia Family Health
Attention: Provider Correspondence
P.O. Box 22278
Pittsburgh, PA 15222
Administrative
claims review
Claims that need to be reviewed based upon administrative, policy, or processing
issues can be discussed with a Provider Services Representative via a phone call to
WVFH at 1-855-412-8002 or forward all of the appropriate documentation via
mail, i.e. the claim, medical record, referral form, and notations regarding
telephone conversations to:
West Virginia Family Health
Attention: Claims Review Department
P.O. Box 22278
Pittsburgh, PA 15222
For inquiries received in the mail, Claims Review Representatives evaluate
whether the documentation attached to the claim is sufficient to allow it to be
reconsidered. Inquiries received in the mail that qualify for adjustments will be
reprocessed, and claim information will appear on subsequent remittance
advices. Claims that do not qualify for reconsideration will be responded to via a
letter. All review requests must be received within 180 days of the initial
remittance advice.
Continued on next page
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3.2 CLAIMS REVIEW, Continued
Medical
claims
review
Claims rejected for services that did not have medical records attached or the
appropriate referrals or authorizations are subject to a Medical Management
Review. All claim records should be sent to WVFH. When submitting a written
request for a claim review, please provide:
• A copy of the WVFH Remittance Advice
• The member’s name and WVFH Identification Number
• The reason the review is requested and include as much supporting
documentation as possible to allow for a complete and comprehensive
review
• Date(s) of service in question
• A copy of the medical record for the service(s) in question (if applicable)
In the event that the claim cannot be reprocessed administratively, a medical
necessity review is undertaken. The records will be reviewed by a medical review
nurse. If the medical review nurse cannot approve the services, a WVFH Medical
Director makes the final decision to approve or deny the claim. A final decision is
made within 30 days from receipt of the inquiry. If the Medical Director does not
approve the services, a denial letter is sent to the practitioner. If the practitioner is
not satisfied with the results of the medical necessity review, a First Level Appeal
can be requested.
Claims inquiries for administrative/medical review should be mailed to:
West Virginia Family Health
Attention: Claims Review Department
P.O. Box 22278
Pittsburgh, PA 15222
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3.2 COORDINATION OF BENEFITS
Coordination
of benefits
policy
Some WVFH recipients have other insurance coverage. WVFH, like the Medicaid
Program, is the payer of last resort on claims for services provided to members
with other insurance coverage. WVFH may not delay or deny payment of claims
unless the probable existence of third party liability is established at the time the
claim is submitted.
WVFH will process and pay EPSDT visits as primary even when our records indicate
WVFH is secondary and a primary plan exists if an explanation of benefits (EOB) is
not attached. If an EOB is attached to the EPSDT or prenatal claim, coordination of
benefits will be applied. We will continue to coordinate benefits and require the
primary EOB when submitting the delivery claim.
Billing process
when WVFH is
the secondary
payer
In order to receive payment for services provided to members with other
insurance coverage, the practitioner must first bill the member’s primary
insurance carrier using the standard procedures required by the carrier. Upon
receipt of the primary insurance carrier’s EOB, the practitioner should submit a
claim to WVFH. The practitioner must:
1. Follow all WVFH referral and authorization procedures.
2. File all claims within timely filing limits as required by the primary
insurance carrier.
3. Submit a copy of the primary carrier’s EOB with the claim to WVFH within
365 days of the date of the primary carrier’s EOB.
4. Be aware that secondary coverage for covered fee-for-service items is
provided according to a benefit-less-benefit calculation.
5. The amount billed to WVFH must match the amount billed to the primary
carrier. WVFH will coordinate benefits; the provider should not attempt to
do this prior to submitting claims.
When a claim is submitted by a practitioner without an EOB from the auto
insurance or a casualty plan, and the original bill does not include any notation of
a primary payer payment, WVFH must take a primary position on the claim and
not deny to the extent that plan criteria was followed. The practitioner has the
option of submitting an original claim; however, it must be submitted within 12
months. These claims will be denied for timely filing if they are not received within
12 months of service. The 12-month rule for Third Party Liability DOES apply to
auto and casualty when the practitioner attaches either an EOB or auto casualty
exhaustion letter. If the practitioner submits the claim with the EOB, WVFH will
coordinate benefits.
Continued on next page
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3.2 COORDINATION OF BENEFITS, Continued
Conflict
in primary
coverage
status
If a member indicates they no longer have primary coverage, but the State System
contains information indicating other medical coverage is still active, the member
should contact his or her caseworker to have the State System updated. If this is
not possible, the practitioner may contact the primary carrier and request written
verification of the coverage.
When WVFH receives a letter from the primary carrier indicating that the member
no longer has coverage, WVFH will use the letter to investigate the situation and
verify if the coverage is cancelled and if there is a new plan covering the member.
If WVFH’s investigation confirms that the member no longer has primary
coverage, WVFH will submit an electronic request to the State to update the
system. WVFH will update our system immediately and reprocess claims finalized
within the 180 day period prior to the date of the onset of the investigation.
Specialty/
fee-for-service
providers
If a member has other coverage, the other carrier is always the primary insurer.
The specialist will bill the other insurer and the other insurer will issue payment
with an EOB, which outlines the payment made for each procedure. The specialist
will then submit a copy of the EOB with a copy of the claim to WVFH for secondary
coverage. The claim must be received by WVFH within 12 months of the date of
the EOB. If required, all WVFH authorization and referral requirements must be
met in order for payment to be issued.
If the member has commercial insurance, and the commercial carrier’s payment is
greater than WVFH’s payment if WVFH were primary, then the following
reimbursement example would apply. The primary carrier amount is the basis for
the benefit determination of WVFH’s liability when the practitioner is a Network
practitioner with the primary plan. The primary carrier allowable paid amount is
used as the basis for the benefit determination of WVFH’s liability when there is a
patient responsibility remaining after the primary carrier has processed the claim.
Example of practitioner participating with Primary Plan:
Practitioner Charges
Primary Carrier Allowable
Primary Payment (80% of Allowable)
WVFH Allowable if Primary
WVFH compares the Primary Carrier Payment to the WVFH Allowable
WVFH does not issue payment
$1,500
$1,000
$800
$600
$800 vs. $600
$0
Example of patient responsibility remaining after Primary plan payment:
Practitioner Charges
Primary Care Allowable
Primary Payment (80% of Allowable)
Patient Responsibility Under Primary Plan
WVFH Allowable if Primary
WVFH compares the Primary Carrier Payment to the WVFH Allowable
WVFH Issues Payment
$1,500
$1,000
$800
$200
$850
$800vs. $850
$50
Continued on next page
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3.2 COORDINATION OF BENEFITS, Continued
Medicare
Often, a WVFH member’s other insurance carrier is Medicare Fee-for-Service.
When Medicare is the other insurance, the following processing criteria applies:
• Referrals and authorizations are not required for services covered by
Medicare. Once Medicare benefits have been exhausted, or if a service is
not covered by Medicare WVFH referral and authorization criteria will
apply.
• For Medicare Part A and Medicare Part B services, coverage is provided
according to a benefits-less-benefits calculation.
WVFH determines the amount that would normally be paid under the plan using
the allowable amount from the Medicare Plan as the billed amount. If the amount
WVFH would pay is more than the amount Medicare pays, then WVFH may pay
the difference up to the maximum allowable, contingent on the benefit less
benefit calculation. If the amount WVFH would pay is equal to or less than the
amount Medicare pays, WVFH does not issue any additional payment.
For Medicare services that are not covered by Medicaid or WVFH, WVFH must pay
cost sharing to the extent that the payment made under Medicare for the service
and the payment made by WVFH does not exceed eighty percent (80%) of the
Medicare approved amount.
Example A
Example B
Practitioner’s Charges
Deductible is satisfied
Medicare Allowable
Medicare Payment (80% of Allowable)
WVFH Allowable if Primary
WVFH compares the Medicare Payment
to the WVFH Allowable
WVFH does not issue payment
$1,500
-0$1,000
$800
$600
$800 vs.
$600
-0-
Practitioner’s Charges
Deductible is satisfied
Medicare Allowable
Medicare Payment (80% of Allowable)
WVFH Allowable if Primary
WVFH compares the Medicare Payment to
the WVFH Allowable
WVFH Issues Payment for the Difference
$1,500
-0$1,000
$800
$850
$800 vs.
$850
$50
Example C
Practitioner’s Charges
Medicare Allowable
Medicare applies $50 to Satisfy the
Deductible
Medicare Payment (80% of Allowable)
Remaining after Deductible is Met
WVFH Allowable if Primary
WVFH compares the Medicare Payment to
the WVFH Allowable
WVFH Issues Payment for the Difference
$1,500
$1,000
$50
$760
$850
$760 vs.
$850
$90
Continued on next page
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3.2 COORDINATION OF BENEFITS, Continued
Nursing
care
WVFH coordinates benefits with a commercial plan using a benefits-less-benefits
approach for limited nursing care services and for expanded services. However,
for these specific services only, the total amount billed to the primary plan will be
the basis for the benefit determination of WVFH’s liability.
Example A
Nursing Charges
Primary Carrier Allowance
Primary Carrier Payment
WVFH Allowable If Primary
WVFH compares the Primary Carrier Payment to the WVFH Allowable
WVFH Issues Payment
$1,000
$600
$500
$800
$500 vs. $800
$300
WVFH’s normal claims processing procedures for Enrollees with other primary
insurance require that a primary carrier Explanation of Benefits (EOB) be
submitted for each date of service.
Subrogation
According to WVFH’s agreement with BMS, if a member is injured or becomes ill
through the act of a third party, medical expenses may be covered by casualty
insurance liability insurance or litigation. Any correspondence or inquiry
forwarded to WVFH by an attorney, practitioner of service, insurance carrier, etc.
relating to a personal injury accident or trauma-related medical service, or which
in any way indicates that there is, or may be, legal involvement, will be handled by
WVFH’s Legal Department.
Claims submitted by a provider and without an EOB statement from auto
insurance or casualty plans without any notation on the original bill of the primary
payer, will be processed by WVFH similar to any other claims. WVFH may neither
unreasonably delay payment nor deny payment of claims because they are
involved in injury stemming from an accident, such as a motor vehicle accident,
where the services are otherwise covered. Timely filing criteria of twelve (12)
months applies, and original claims must be received timely to be eligible for
payment.
EOBs or auto/workers compensation/casualty exhaustion letters qualify for
consideration if they are received within twelve (12) months of the date of the
EOB/letter along with submission of the initial bill in order for WVFH to coordinate
benefits.
All requests from legal representatives, and/or insurers for information concerning
copies of patient bills or medical records must be submitted to WVFH’s Legal
Department. A cover letter identifying the date and description of the injury,
Continued on next page
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3.2 COORDINATION OF BENEFITS, Continued
Subrogation
(continued)
requested dates of services for billing statements, and release of information
signed by the member should be forwarded to the following address:
West Virginia Family Health
Attention: Legal/Regulatory Affairs
P.O. Box 1948
Parkersburg, WV 26102-1948
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3.2 PRIMARY CARE SERVICES
PCP
reporting
PCPs are required to report all the services they provide for WVFH members to
WVFH. To facilitate reporting, WVFH will accept encounter information on the
industry standard claim forms or the claim can be submitted via EDI. Charges for
encounters/visits should be submitted within sixty (60) days from the date of
service but will be accepted up to 12 months from the date of service. The
encounter information will be reported back to the PCP on a remittance advice.
Practitioners are required to report all services provided to WVFH members with
primary insurance coverage by submitting a claim with a copy of the explanation
of benefits regardless of whether or not additional payment is expected. Members
seeking care, regardless of primary insurer, are required to contact their PCP and
use Network practitioners or obtain appropriate authorization for practitioners
outside of the network.
Vaccines for
Children (VFC)
All Medicaid eligible recipients under 19 years of age are eligible for Vaccines For
Children (VFC) vaccines. Providers should follow the CDC’s recommendations
about implementing a two-directional borrowing policy when vaccine supplies
are depleted.
For this policy, providers purchase an initial inventory of appropriate private stock
vaccines, and if the private stock vaccine is not used and is nearing the expiration
date, the clinic can use the private stock on VFC-eligible children and document
on the borrowing form that private stock vaccine was administered to a VFCeligible child because the private stock was short-dated. The clinic can then
replace the used private stock with VFC vaccine and document when that private
stock was replaced.
Billing for
fluoride
varnish
applications
WVFH will reimburse those PCPs properly certified for the application of topical
fluoride varnish on a fee-for-service basis. To receive payment for this service, the
provider must complete training through West Virginia University School of
Dentistry.
The Bureau of Medical Services (BMS) allows coverage of two fluoride varnish
applications per year (one every six months). The first application must be
provided and billed in conjunction with a comprehensive well-child exam as
reported under the CPT codes listed in the table below. The second fluoride
varnish application can be reimbursed during the 12-month subsequent period,
Continued on next page
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3.2 PRIMARY CARE SERVICES, Continued
Billing for
fluoride
varnish
applications
and may be billed in conjunction with the HCPCS code outlined in the table
below.
CODE
DESCRIPTION
99381-99382
99391-99392
Comprehensive well-child exam codes
for children less than 1 year and up to
age 4 (note FV coverage under this
program is only through age 3)
Topical fluoride varnish; therapeutic
application for moderate to high caries
risk patients.
D1206
D0145
Oral Evaluation for patient under three
years of age and counseling with
primary caregiver.
COMMENTS
Oral evaluation and counseling are
components of comprehensive well –
child exams
Covered 2 times per year for children up
to age 3; 1st application must be billed in
conjunction with one of the
comprehensive well child exam codes
listed above
Covered once per year in conjunction
with 2nd fluoride varnish application;
cannot be covered when comprehensive
well-child exam is billed on the same day
and at least 180 days after billing for the
comprehensive well child-exam
In order to bill (D1206) and receive reimbursement PCPs must submit a copy of
the training certificate to:
West Virginia Family Health – Provider Correspondence
Attention: Training Certification
P.O. Box 22190
Pittsburgh, PA 15222
At the top of the certificate, please include your Medicaid provider identification
number and/or WVFH Provider Number. PCPs will not be reimbursed for
providing the topical fluoride varnish before we have a copy of the training
certificate on file. Your practice will receive written notification confirming receipt
of your certificate and provide a date when you may begin billing.
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3.2 CLAIM CODING SOFTWARE
Verifying
clinical
accuracy
WVFH uses a fully automated coding review product that programmatically
evaluates claim payments to verify the clinical accuracy of professional claims in
accordance with clinical editing criteria. This coding program contains complete
sets of rules that correspond to CPT-4, HCPCS, ICD-9, AMA, and CMS guidelines (or
successor forms and guidelines) as well as industry standards, medical policy, and
literature and academic affiliations.
The program used at WVFH is designed to assure data integrity for ongoing data
analysis and reviews procedures across dates of service and across providers at
the claim, practitioner, and practitioner-specialty level.
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3.2 BILLING
Clean claim
requirements
A “clean claim” as used in this section means a claim for payment for a health care
service that has no defect or impropriety. A defect or impropriety shall include
lack of required substantiating documentation or a particular circumstance
requiring special treatment that prevents timely payment from being made on
the claim. A claim from a health care provider who is under investigation for fraud
or abuse regarding that claim will not be considered a “clean claim.”
In addition, a claim shall be considered clean if the appropriate corresponding
referral has been submitted or the appropriate authorization has been obtained in
compliance with WVFH’s Provider Manual and the following elements of
information are furnished on a standard UB-04 or 1500 form (or their
replacements with CMS designations, as applicable) or an acceptable electronic
format through a WVFH-contracted clearinghouse:
1. Patient name;
2. Patient medical plan identifier;
3. Date of service for each covered service;
4. Description of covered services rendered using valid coding and
abbreviated description;
5. ICD-9 surgical diagnosis code (as applicable) (or its replacement);
6. Name of practitioner/provider and plan identifier;
7. Provider tax identification number;
8. Valid CMS place of service code;
9. Billed charge amount for each covered service;
10. Primary carrier EOB when patient has other insurance;
11. All applicable ICD-9-CM diagnosis codes—inpatient claims include
diagnoses at the time of discharge or in the case of emergency room
claims, the presenting ICD-9-CM diagnosis code (or any replacements);
12. DRG code for inpatient hospital claims.
Completion
of claim forms
WVFH processes medical expenses upon receipt of a correctly completed CMS
form or correctly completed UB-04. Sample copies of a UB-04 and a 1500 form can
be found at the end of this unit. A description of each of the required fields for
each form is identified later in this unit. Paper claim forms must be submitted on
original forms printed with red ink.
A claim without valid, legible information in all mandatory categories is subject to
rejection/denial. To assure reimbursement to the correct payee, the WVFH
practitioner number must be included on every claim.
Continued on next page
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3.2 BILLING, Continued
Completion
of claim forms
(continued)
To comply with encounter data reporting, PCPs and specialty care practitioners
must submit claims under the individual practitioner identification number rather
than the practice or group identification number. Any claim billed on a CMS form
must include the individual practitioner identification number (box 31 on the
1500 Form).
Please note that it is extremely important to promptly notify WVFH of any
change that involves adding practitioners to any group practice, as failure to
do so may result in a denial of service.
WVFH will process claims utilizing individual practitioner numbers even if the
individual practitioner number is not included on the claim. The only exception to
the individual practitioner number requirement applies to UB charges for
practitioner services when a remittance advice is issued to a hospital facility.
WVFH recommends that practitioners submit the appropriate copy of the Referral
Form (if the telephonic DIVA paperless system is not used) with their claim in
order to facilitate proper reimbursement.
All claims must have complete and accurate ICD-9-CM (or its replacement)
diagnosis codes for claims consideration. If the diagnosis code requires, but does
not include the fourth or fifth digit classification, the claim will be denied.
Any person who knowingly files a statement of claim containing any
misrepresentation or any false, incomplete or misleading information may
be guilty of a criminal act punishable under law and may be subject to civil
penalties. By signing a claim for services, the practitioner certifies that the
services shown on the claim were medically indicated and necessary for the
health of the patient and were personally furnished by the practitioner or an
employee under the practitioner’s direction. The practitioner certifies that the
information contained in the claim is true, accurate, and complete.
Claims filing
address
Questions?
WVFH’s claim office address is:
West Virginia Family Health
Claims Processing Department
P.O. Box 830499
Birmingham, AL 35283
Any questions concerning billing procedures or claim payments can be directed
to WVFH’s Provider Services Department at 1-855-412-8002.
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3.2 EARLY AND PERIODIC SCREENING, DIAGNOSTIC, AND
TREATMENT (EPSDT) SERVICES
EPSDT claim
submission
time frame
All Early and Periodic Screening, Diagnostic and Treatment (EPSDT) screening
services, including vaccine administration fees, should be submitted to WVFH on
an industry standard claim form or via EDI within sixty (60) days from the date of
service to permit timely member outreach.
Claims will be accepted up to 365 days following the date of service, but will result
in member and provider outreach for missing EPSDT screens until the claim is
submitted.
FQHC/RHC
billing
Federally Qualified Health Centers (FQHCs)/Rural Health Centers (RHCs)
Claims for services rendered to Medicaid members must be filed by the
RHC/FQHC on the UB04 claim form or the ASC X12N 837 (005010X096A1)
electronic claim format (or successor forms and formats). The encounter code is
T1015, billed with Revenue Code 52X for a medical visit.
The RHC/FQHC claim must list actual CPT/HCPCS procedure codes and
appropriate revenue codes to identify the services included in the encounter.
Each procedure code must have the –EP modifier. The facility may bill the actual
charge or indicate a charge of zero for those individual services, but must bill the
total charge for the encounter.
1500 paper
format
requirements
All EPSDT screening services must be reported with the age-appropriate
evaluation and management code (99381-99385, 99391-99395, 99431 and 99435)
along with the EP modifier and ICD9 (or its replacement) codes V20 – V202, V70, or
V703 to V709.
The EP modifier must follow the evaluation and management code in the first line
of Block 24D on the claim form. Use CPT Modifier (52 or 90) plus CPT code when
applicable.
• Diagnosis codes V20.0, V20.1 or V20.2 must be noted in Box 21 and should
be used except when billing for newborns in an inpatient setting (POS 21).
V30.00 is primary with V20.0, V20.1 or V20.2 as secondary.
• Report visit code “03” in box 24(h) of the1500 form (or its replacement)
when providing EPSDT screening service.
When a referral is made for follow up on a defect, physical or mental illness or a
condition identified through an EPSDT screening, referral code indicator “Y” must
be listed in box 24H of the 1500 form (or its replacement).
Continued on next page
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3.2 EARLY AND PERIODIC SCREENING, DIAGNOSTIC, AND
TREATMENT (EPSDT) SERVICES, Continued
1500
EDI format
requirements
All EPSDT screening services must be reported with the age-appropriate
evaluation and management code (99381-99385, 99391-99395, 99431 and 99435)
along with the EP modifier.
The EP modifier must follow the evaluation and management code in the first
position on the claim form. Use CPT Modifier (52 or 90) plus CPT code when
applicable.
Populate the SV111 of the 2400 loop with a “yes” for an EPSDT claim (this is a
mandatory federal requirement).
Populate the Data Element CLM12 in the 2300 Claim Information Loop with “01”
(meaning EPSDT).
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3.2 OBSTETRICAL CARE SERVICES
Intake visit
and PRSI
The first visit with an obstetrical patient is considered the intake visit, or if a
patient becomes a WVFH member during the course of her pregnancy, her first
visit as a WVFH member is considered to be her intake visit.
At the intake visit, a West Virginia Prenatal Risk Screening Instrument (PRSI) form
must be completed. A copy of the PRSI must be faxed to WVFH’s Maternity Case
Management Department within 2-5 business days of the intake visit and at
least 30 days prior to delivery. The PRSI Form is not a claim; however, the PRSI
Form must be received by WVFH in order to process the claim for the intake visit.
The initial prenatal visit MUST be rendered within the first trimester and the WV
PRSI Form must be completed during the visit and faxed to WVFH’s Maternity Care
Management department at 1-855-430-9847 within 2-5 business days of the
visit.
Billing visits
and delivery
Obstetric practitioners are reimbursed on a per visit basis. All visits and dates of
service must be included on the claim form and identified with appropriate
maternity codes for appropriate reimbursement. Delivery charges are to be coded
with CPT Codes. The date billed for a Delivery Code, in CPT code format, must be
the actual date of service. Submit claims on an industry standard form within
twelve (12) months to receive payment for the visit.
Newborn
charges
All charges for newborns that become enrolled in the plan are processed under
the newborn name and newborn’s WVFH identification number. For prompt
payment, please submit claims with the newborn patient information or the claim
will be pended for manual research. Inpatient hospital bills for newborns should
be submitted separately from the mom’s confinement.
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3.2 HOSPITAL SERVICES
Overview
Hospital claims are submitted to WVFH on a UB-04 Form. To assure that claims are
processed for the correct member, the member’s eight-digit WVFH identification
number must be used on all claims.
Practitioners rendering services in an outpatient hospital clinic should include
their individual provider number on the claim when submitting on a UB-04 or a
1500 Form, or successor form.
To aid in the recording of payment, patient account numbers recorded on the
claim form by the practitioner are indicated in the Patient ID field on the WVFH
remittance advice.
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3.2 UB-04 DATA ELEMENTS FOR CLAIMS SUBMISSION
UB-04 DATA ELEMENTS FOR SUBMISSION OF CLAIMS FOR PAPER CLAIMS
Note: EDI Requirements Must be Followed for Electronic Claims Submission
``
Field
Description
Requirements
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24-30
31
32-35
36
37
38
Practitioner Name, Address, Phone Number
Unlabeled Field
Patient Control Number
Type of Bill
Federal Tax Number
Statement Covers Period
Covered Days
Non-covered Days
Coinsurance Days
Lifetime Reserve Days
Unlabeled Field
Patient Name
Patient Address
Patient Birth Date
Patient Sex
Patient Marital Status
Admission/Start of Care Date
Admission Hour
Admission Type
Source or Admission
Discharge Hour
Patient Status
Medical Record Number
Condition Codes
Unlabeled Field
Occurrence Codes and Dates
Occurrence Span Codes and Dates
Internal Control Number
Responsible Party Name and Address
39-41
Value Codes and Amounts
42
43
44
45
46
47
48
Revenue Codes
Descriptions
HCPCS/Rates
Service Dates
Service Units
Total Charges
Non-covered Charges
Required
Not Required
Required
Required
Required
Required
Required, If Inpatient
Required, If Inpatient
Required, if inpatient
Not Required
Not Required
Required
Required
Required
Required
Not Required
Required, If Inpatient
Required, If Inpatient
Required, If Inpatient
Required, if inpatient
Required
Required
Not Required
Minimum of One Required, If Applicable
Not Required
Minimum of One Required, If Applicable
Minimum of One Required, If Applicable
Not Required
Not Required
Required for DRG Reimbursement, Value
Code Record Type 41 must be entered as
ZZ and DRG Code must be entered in Value
Amount Field
Required
Required
Required, If Outpatient
Required, If Outpatient
Required
Required
Required, If Applicable
Continued on next page
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3.2 UB-04 DATA ELEMENTS FOR CLAIMS SUBMISSION, Continued
Field
Description
Requirements
49
50
Unlabeled Field
Payer Identification
51
Practitioner Number
52
53
54
55
56
57
58
59
Release of Information Certification Indicator
Assignment of Benefits
Prior Payments
Estimated Amount Due
Unlabeled Field
Unlabeled Field
Insured’s Name
Patient Relationship to Insured
60
Certificate-Social Security Number-Health Insurance
Claim-Identification Number
61
62
63
64
65
66
67
68-75
76
77
78
79
80
81
82
83
84
85
86
Group Name
Insurance Group Number
Treatment Authorization Code
Employment Status Codes
Employer Name
Employer Location
Principal Diagnosis Code
Other Diagnosis Codes
Admitting Diagnosis Code
E Code
Unlabeled Field
Procedure Code Method Used
Principal Procedure Code and Date
Other Procedure Codes and Date
WVFH Individual Provider ID Number
Other Practitioner Identification
Remarks
Provider Representative
Date
Not Required
Required
WVFH Practitioner Identification Number
Required
Not Required
Not Required
Required, If Applicable
Not Required
Not Required
Not Required
Required
Not Required
WVFH Enrollee Identification Number
Required (11-digit MA Recipient Number
acceptable for electronic claims)
Required
Not Required
Required, If Applicable
Not Required
Not Required
Not Required
Required
Required, If Applicable
Required, If Applicable
Not Required
Not Required
Not Required
Required, if inpatient only
Required, if inpatient only
Required
Required
Not Required
Required
Required
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3.2 SAMPLE UB-04 CLAIM FORM
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3.2 1500 DATA ELEMENTS FOR CLAIMS SUBMISSION
1500 DATA ELEMENTS FOR SUBMISSION OF CLAIMS FOR PAPER CLAIMS
Note: EDI Requirements Must be Followed for Electronic Claims Submission
Field #
Description
Requirements
1
Insurance Type
1a
Insured Identification Number
2
3
4
5
6
7
8
9
9a
9b
9c
9d
Patient’s Name
Patient’s Birth Date
Insured’s Name
Patient’s Address
Patient Relationship to Insured
Insured’s Address
Patient Status
Other Insured’s Name
Other Insured’s Policy or Group Number
Other Insured’s Date of Birth, Sex
Employer’s Name or School Name
Insurance Plan Name or Program Name
Is Patient Condition Related to:
a.
Employment Auto accident
b.
Other accident
Required
WVFH Member Identification Number
Required (10-digit MA Recipient Number
acceptable for Electronic Claims)
Required
Required
Required
Required
Required
Required
Required
Required, If Applicable
Required, If Applicable
Required, If Applicable
Required, If Applicable
Required, If Applicable
10
10d
Reserved for Local Use
11
11a
11b
11c
11d
12
13
14
Insured’s Policy Group or FECA Number
Insured’s Date of Birth, Sex
Employer’s Name or School Name
Insurance Plan Name or Program Name
Is There Another Health Benefit Plan?
Patient or Authorized Person’s Signature
Insured’s or Authorized Person’s Signature
Date of Current: Illness OR Injury OR Pregnancy
If Patient has had Same or Similar Illness, Give First
Date
Dates Patient Unable to Work in Current Occupation
Name of Referring Practitioner or Other Source
Identification Number of Referring Practitioner
Hospitalization Dates Related to Current Services
Reserved for Local Use
Outside Lab
Diagnosis or Nature of Illness or Injury
Medical Resubmission Code
Prior Authorization Number
15
16
17
17a
18
19
20
21
22
23
Required, If Applicable
Not Required (see instructions for EPSDT
claims instructions)
Required
Required, If Applicable
Required, If Applicable
Required, If Applicable
Required, If Applicable
Required
Required
Required, If Applicable
Not Required
Required, If Applicable
Required
Not Required
Required, If Applicable
Not Required
Not Required
Required
Not Required
Not Required
Continued on next page
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3.2 1500 DATA ELEMENTS FOR CLAIMS SUBMISSION, Continued
Field #
Description
Requirements
24a
24b
24c
Required
Required
Not Required
24e
24f
24g
Date(s) of Service
Place of Service
Type of Service
Procedures, Services, or Supplies
CPT/HCPCS/Modifier
Diagnosis Code
Charges
Days or Units
24h
EPSDT Family Plan
24i
24j
24k
25
EMG
COB
Reserved for Local Use
Federal Tax Identification Number
26
Patient Account Number
27
28
29
30
Accept Assignment
Total Charge
Amount Paid
Balance Due
Signature of Practitioner or Supplier including
degrees or credentials
Name and Address of Facility Where Services were
Rendered
Practitioner’s, Supplier’s Billing Name, Address, Zip
Code and Phone Number
24d
31
32
33
Required
Required
Required
Required
Not Required (see instructions for EPSDT
claims submissions)
Not Required
Not Required for WVFH Primary Claims
Not Required
Required
Not Required, but WVFH includes
payment information when present to
assist with reconciliation in provider
records
Not Required
Required
Not Required
Not Required
WVFH Individual Practitioner Name and
Date Required
Name and Address Required
WVFH Vendor Name, Address, and Number
Required
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3.2 SAMPLE 1500 CLAIM FORM
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CHAPTER 3: POLICIES AND PROCEDURES
UNIT 3: REIMBURSEMENT
IN THIS UNIT
TOPIC
Introduction
Facility Providers
Physicians and Other Providers
Rate Changes
Directed Payments to Certain Qualified Providers
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3.3 INTRODUCTION
Overview
West Virginia Family Health (WVFH) will reimburse contracted network providers
for covered services rendered to the West Virginia Medicaid population.
Reimbursements to network providers for billed and covered claims will occur on
a weekly basis via electronic funds transfer (EFT).
This unit provides an overview of the various types of reimbursement
methodologies utilized by the Bureau for Medical Services (BMS) and emulated by
Highmark West Virginia. In some cases, the network agreement itself includes the
detailed components of the pricing methodology as well as the actual payment
rates.
Questions regarding specific reimbursement methods or rates for WVFH network
providers should be directed to the Office of Provider Contracting and
Reimbursement of Highmark West Virginia.
BMS
Reimbursement
Hold Harmless
BMS is not liable or responsible for payment of covered services rendered to
Members pursuant to provider agreement.
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3.3 FACILITY PROVIDERS
Introduction
The reimbursement methodologies for the various facility and organizational
providers with which Highmark Blue Cross Blue Shield West Virginia (“Highmark
West Virginia”) contracts on behalf of the West Virginia Family Health (WVFH) are
summarized below.
Contracted hospital rates such as DRGs (Diagnosis-Related Groups), Per Diems,
Case Rates, and Percent of Charge are based upon the current effective Bureau of
Medical Services (BMS) method and rate with an additional five percent (5%)
included.
Hospital
inpatient care
services
WVFH reimburses the current Bureau of Medical Services (BMS) effective rate of
reimbursement for each inpatient discharged from an acute care hospital by the
DRG classification system. The DRGs are updated annually based on BMS review
and recalculation using adjustment/severity factors applicable to certain types of
admissions.
WVFH follows BMS reimbursement methodology by applying the special
prospective payment rules to community hospitals. Psychiatric, rehabilitations,
and rural primary care hospitals are reimbursed on a cost-related basis. The
current effective BMS cost-related rate is increased by five percent (5%) and
updated annually.
If a member is confined to an inpatient care facility on the effective date for initial
enrollment with WVFH coverage of inpatient facility charges (including charges at
a transfer facility if the member is transferred during the stay or within the facility)
will be the responsibility of BMS until the member is discharged. WVFH is
responsible for all covered services provided on or after the effective date of
WVFH enrollment including but not limited to emergency transportation,
professional fees during the inpatient stay, and outpatient care.
For a WVFH member receiving inpatient care at the time of disenrollment from
WVFH, coverage of inpatient facility charges (including charges to a transfer
facility if the member is transferred during the stay or within the facility) provided
after the effective date of disenrollment will be the responsibility of WVFH until
the member is discharged. Coverage of all other covered services (included by not
limited to emergency transportation, professional fees during the inpatient stay
and outpatient care) during the inpatient stay will be the responsibility of BMS as
of the effective date of disenrollment from WVFH.
WVFH is not responsible for the inpatient facility charges for a member who is no
longer eligible for Medicaid coverage as of the first of the month following the
loss of Medicaid coverage.
Continued on next page
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3.3 FACILITY PROVIDERS, Continued
Hospital
outpatient
services
WVFH reimburses hospital outpatient services based on the current prevailing
methodology utilized by BMS.
• Emergency Room and Observation are reimbursed using the BMS Medicaid
fee schedule.
• Surgeries and recovery are reimbursed at the set BMS fee amount
multiplied by the total unit of time.
• Radiology, physical therapy, and occupational therapy services, as well as
cardiac and pulmonary rehabilitation, are reimbursed in the same manner
as BMS reimbursement.
• Critical Access Hospital services are reimbursed at the current effective
BMS encounter rate as set by the Office of Audits or by fee for service.
PROVIDER TYPE
Acute
• Inpatient
• Outpatient
Critical Access
• Inpatient
• Outpatient
METHOD(S) OF PRICING
DRG
E/R, Recovery and Observation based on Fee Schedule x units,
Radiology, PT and OCC Therapies based on BMS RBRVS
Cost Based Per Diem
O/P Encounter Rate set by Office of Audits or Fee for Service* Cost
basis for other service types
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3.3 PHYSICIANS AND OTHER PROVIDERS
Overview
Physicians and other providers are generally reimbursed at the prevailing Bureau
of Medical Services (BMS) Resource Based Relative Value Scale (RBRVS) fee
schedule multiplied by the BMS conversion factor. Based on BMS treatment and
reimbursement of professional providers, the following types of providers are
reimbursed under the effective BMS RBRVS fee schedule:
• Physicians (including doctors of medicine and osteopathy and Physician
Assistants working under their supervision)
• Limited licensed practitioners (including doctors of optometry, podiatry,
dental surgery and dental medicine: oral and maxillofacial surgery, and
chiropractors)
• Independently practicing Physical Therapists and Occupational Therapists
for outpatient services only
• Suppliers of the technical component of radiology or diagnostic services
• Family and Pediatric nurse practitioners’
• Nurse Midwives
• Certified Registered Nurse Anesthetists
ANCILLARY PROVIDERS
PROVIDER TYPE
Ambulance - Ground
Ambulatory Surgery Centers
Durable Medical Equipment (A, E, K, L Codes)
Hearing Aid Facilities
Home Health Agencies
Home Infusion Therapy
Hospice
Renal Dialysis
Skilled Nursing Facilities
METHOD(S) OF PRICING
BMS Medicaid Fee Schedule, Separate rates for ground/air
BMS Medicaid Fee Schedule
BMS Medicaid Fee Schedule
BMS Medicaid Fee Schedule
Per Visit, BMS Medicaid Fee Schedule
BMS Fee schedule for per diem services, % of AWP for drugs
BMS Per Diem
BMS Global Fee
BMS Per Diem
PHYSICIAN SERVICES AND OTHER PROFESSIONALS
PROVIDER TYPE
Medical
Maternity
Lab
Dental
Vision
Anesthesiology
METHOD(S) OF PRICING
WV RBRVS x BMS conversion factor
WV RBRVS x BMS conversion factor and Medicaid Fee Schedule
BMS Fee Schedule, Clinical Labs BMS RBRVS Fee Schedule
WV RBRVS x conversion factor for dental surgeries only
BMS Medicaid Fee Schedule
BMS Conversion Factor x sum of base + time units
Continued on next page
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3.3 PHYSICIANS AND OTHER PROVIDERS, Continued
Dental
services
The West Virginia RBRVS fee schedule multiplied by the BMS conversion factor is
used to pay for dental surgeries covered when billed by a physician. Other
covered dental services are paid using the BMS fee schedule which establishes a
fee for each American Dental Association (ADA) procedure code. In each case, the
Highmark West Virginia reimbursement is based on the lower of the amount of
charges for the service or the fee schedule amount.
Durable
medical
equipment
(DME)
Durable medical equipment (DME), medical supplies, and orthotic and prosthetic
devices are reimbursed in alignment with BMS classifications. A separate method
applies to each class and the payment is based upon the rental or purchase basis
of the item. DME payment is based on the lower of the amount the supplier
charges for the item or the fee schedule amount, and is applicable to payments
for repairs and maintenance.
Free-standing
ambulatory
surgical
centers
Reimbursement for covered services performed in a free standing ambulatory
surgical setting follows the BMS reimbursement methodology by percent of
applicable fee schedule.
Home health
services
The current effective BMS fee schedule is the basis used to determine the amount
to be paid for skilled home health care for the following covered services: nursing
care, rehabilitation services, home health aide services, and medical social
services. Each visit for home health care is considered one unit of payment.
Hospice
services
Hospital hospice and home hospice reimbursements are based on the current
Medicaid fee schedule. Nursing home hospice is reimbursed a percentage of the
patient specific nursing home rate.
Laboratory
services
WVFH reimburses for covered laboratory services at the effective Medicaid fee
schedules, with the exception of hospital-based laboratories performing such
tests for their own inpatients. Payment for laboratory services is based on the
lower of the effective Medicaid fee schedule or the amount the network provider
charges for the service. Certain tests exempt from Medicaid’s fee schedule for
clinical diagnostic laboratory services are paid under the RBRVS fee schedule.
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3.3 RATE CHANGES
Policy for
rate changes
Rates for covered inpatient and outpatient services shall remain fixed until such
time that Bureau of Medical Services (BMS) changes its reimbursement to the
contracted network provider or implements an alternative methodology for
reimbursement.
In regard to Hospital inpatient and/or outpatient rates, including cost-based rate
changes, it is the responsibility of the Hospital to notify Highmark West Virginia
of any such changes. Once the Hospital notifies Highmark West Virginia, Highmark
West Virginia shall then update the Hospital’s current outpatient rates by the BMS
percentage change with an effective date fifteen (15) business days after the
Hospital’s notification to Highmark West Virginia. Previously processed claims will
not be adjusted due to any retroactive change implemented by BMS.
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3.3 DIRECTED PAYMENTS TO CERTAIN QUALIFIED PROVIDERS
Directed
Payments
WVFH must reimburse Qualified Providers at the levels directed by the Bureau of
Medical Services (BMS). BMS must provide the levels for the Directed Payments to
WVFH on the State Fiscal Year basis. Qualified Providers include:
1. A non-state, but government owned facility such as a county or city
hospital;
2. University Practice Plans;
3. Public safety net hospitals; and
4. Private hospitals, except for the critical access hospitals.
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CHAPTER 3: POLICIES AND PROCEDURES
UNIT 4: MEMBER AND PROVIDER DISPUTES
IN THIS UNIT
TOPIC
Provider Appeals
Provider Disputes
Member Grievance Process
• Informal Grievances
• Formal Grievances
• External Grievance Review
Member Appeals
Provider Initiated Member Grievances or Appeals
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3.4 PROVIDER APPEALS
Overview
Providers who disagree with a decision to deny authorization or payment have
the right to appeal the decision. WVFH offers providers:
1) An informal and formal appeals process to request reversal of a denial by
WVFH; and
2) An informal and formal dispute process for expressing dissatisfaction with
WVFH decisions which directly impacts the provider.
Types of
provider
appeals
A provider appeal is a request from a Provider for reversal of a denial by WVFH in
regard to three major types of issues:
1. Provider credentialing denial by WVFH. Please see Chapter 2, Unit 2:
Network Credentialing Procedures of the Highmark Blue Shield Office Manual
for more information (also available on the Highmark West Virginia Provider
Resource Center under Administrative Reference Materials).
2. Claim Denials. Claims denied by WVFH for Network providers. This includes
payment denied for services already rendered by the Network provider to the
member.
a. Informal Process. Claims that need to be reviewed based upon
administrative, policy, or processing issues can be discussed with a
Provider Services Representative. For inquiries received in the mail, Claims
Review Representatives evaluate whether the documentation attached to
the claim is sufficient to allow it to be reconsidered. Inquiries received in
the mail that qualify for adjustments will be reprocessed, and claim
information will appear on subsequent remittance advices. Claims that do
not qualify for reconsideration will be responded to via a letter. All review
requests must be received within 120 days of the initial remittance advice.
Informal appeals will completed within thirty (30) days of receipt.
b. Formal Process. If the provider does not agree with the informal appeal
decision, the provider can request a formal appeal. The provider must
submit a written request for a second level appeal or request additional
review on an already denied. The Provider Appeal/Dispute Committee will
review all formal appeals and make a determination within sixty (60) days.
The provider will be informed of the formal appeal decision in writing. The
formal appeal decision is final and binding. For more information
regarding Provider Appeals, please see Chapter 4, Unit 4: Denials,
Grievances, and Appeals of the Highmark Blue Shield Office Manual.
All written appeals must be sent to:
West Virginia Family Health
Attention: Provider Appeals
P.O. Box 22278
Pittsburgh, PA 15222
Continued on next page
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3.4 PROVIDER APPEALS, Continued
Types of
provider
appeals
(continued)
3. Termination of Network Provider Agreement by Highmark West Virginia
or West Virginia Family Health. For more information regarding corrective
action, termination, and appeals, please see Chapter 2, Unit 2: Network
Credentialing Procedures of the Highmark Blue Shield Office Manual (also
available on the Highmark West Virginia Provider Resource Center under
Administrative Reference Materials).
Note: The above process for claim denials is the mechanism for all providers,
regardless of participation status, to appeal denied payment (post-service) for
services rendered to WVFH members. This process will be intended to afford
providers with the opportunity to address issues regarding payment only. Appeals
for services that have not yet been provided will follow the Member Grievance or
Complaint processes. The provider will have an option for an informal and formal
review of the denied payment.
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3.4 PROVIDER DISPUTES
Definition
A provider dispute is when a provider expresses dissatisfaction with a Health
Plan decision that directly impacts the provider. This does not include decisions
concerning Medical Necessity.
Dispute
processes
Following are the informal and formal dispute processes:
• Informal Provider Dispute Process. When a written Provider Dispute is
received, it will be forwarded to the appropriate department within WVFH
for resolution. The dispute will be researched and responded to within
forty-five (45) days of receipt. This initial response is considered the
informal settlement process for the dispute.
• Formal Provider Dispute Process. If a provider disagrees with our initial
response and sends in an additional written inquiry within sixty (60) days of
incident being disputed, the Provider Dispute/Appeals Committee will
hear all formal Provider Disputes and make a determination. Once
received, dispute will be reviewed, and a decision will be rendered within
sixty (60) days after receipt.
Provider Disputes can be requested verbally by contacting WVFH’s Provider
Service Department.
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3.4 MEMBER GRIEVANCE PROCESS
Overview
WVFH provides an informal and a formal grievance (complaint) process for its
members. Members may file grievances with WVFH regarding issues such as
services denied, quality of care, service complaints and payment. A member may
choose either process when filing a grievance.
A provider may file a grievance on the member’s behalf; however, the provider
must be officially appointed as the member’s representative to do so (see Provider
Initiated Member Grievances or Appeals later in this unit for more information).
WVFH will require that documentation is submitted to demonstrate said
appointment prior to initiating grievance proceedings.
Informal
grievances
An informal grievance is an oral expression of dissatisfaction other than those
subject to appeal. The filing limit for an informal grievance is within one (1) year of
the date of the occurrence giving rise to the matter at issue in the grievance.
An informal grievance maybe filed orally by the Member or Member’s appointed
representative by calling WVFH’s toll-free Member Services number at
1-855-412-8001 (TTY/TDD 711or 1-800-982-8771).
Informal grievances are resolved within thirty (30) days of receipt, and a letter
explaining the outcome is mailed to the Member and/or Member’s appointed
representative.
Formal
grievances
Formal grievances are written expressions of dissatisfaction other than those
subject to appeal. If a Member or Member’s appointed representative is not
satisfied with the outcome of an informal grievance, a written formal grievance
may be filed within one (1) year of the date of occurrence or the informal
grievance decision letter.
If the informal grievance determination is made and there is not more than ninety
(90) days before the anniversary of the occurrence, the Member must be granted
that additional time to file the formal grievance. WVFH will accept oral or written
formal grievances; however, an oral grievance will not be processed until the
Member or Member’s appointed representative’s signature is obtained.
If an oral formal grievance is received, WVFH will record the formal grievance on
paper and mail to Member or Member’s appointed representative for signature
along with a self-addressed, postage-paid envelope for Member or Member’s
appointed representative to return.
Continued on next page
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3.4 MEMBER GRIEVANCE PROCESS, Continued
Formal
grievances
(continued)
After receiving a written request, WVFH send an acknowledge letter within five (5)
working days which will advise the Member or Member’s appointed
representative of the following:
• The Member may appoint a representative to act on his or her behalf
 The Member or Member’s appointed representative may submit
additional information in writing or orally.
 The Member or Member’s appointed representative may review all
documentation regarding the formal grievance upon request free of
charge.
• The Member’s right to meet with WVFH during the formal grievance
process.
Formal grievances will be processed within forty-five (45) days of the receipt of
the written request/signed grievance. A letter explaining the outcome is then
mailed to the Member or Member’s appointed representative.
External
grievance
review
If a Member or Member’s appointed representative is not satisfied upon the
exhaustion of the formal grievance review process, a request may be submitted, in
writing, to the Insurance Commissioner by sending the grievance appeal to:
The Office of the Insurance Commissioner
P.O. Box 50540
Charleston, WV 25305-0540
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3.4 MEMBER APPEALS
Overview
An appeal is defined as a request for a review of WVFH’s action to deny or limit
authorization or payment (in whole or in part) for health care services including:
• New authorizations
• Previously authorized services
• A reduction, suspension, or termination of a previously authorized service
• WVFH’s failure to provide services in a timely manner
• WVFH’s failure to resolve grievances or appeals within the timeframe
specified
• WVFH’s denial of a request by a member to receive out-of-network services
when the member resides in a rural area with only one managed care
organization.
The Member must file an appeal within ninety (90) days from the date of the
incident complained of or the date the Member receives the Notice of Action.
Services during If the Member or Member’s appointed representative files an Appeal to dispute a
appeal process decision to terminate, suspend, or reduce a previously authorized course of
treatment that was ordered by an authorized provider where the original period
covered by the original authorization has not expired and the Member requests
an extension of benefits, the Member must continue to receive the services if the
Appeal is submitted within ten (10) days from the mail date on the written Notice
of Action letter.
The benefits shall be continued or reinstated until the Member or Member’s
representative withdraws the appeal, ten (10) days after WVFH mails the
resolution of the appeal unless the Member has requested a State fair hearing
within that ten (10) day time frame, or the time period or service limits of a
previously authorized service have been met. If services are continued during the
appeal process and WVFH upholds its decision to terminate, suspend, or reduce,
the member may be liable for payment of the services received through
continuity.
WVFH letter to
acknowledge
receipt of an
appeal
Within five (5) working days of the receipt of an appeal, WVFH will send an
acknowledgement letter to the Member, the Member’s appointed representative,
and the provider. The letter will include the following information:
• The Member, Member’s appointed representative, or provider that filed on
the Member’s behalf has the right to review information related to the
appeal upon request (free of charge);
Continued on next page
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3.4 MEMBER APPEALS, Continued
WVFH letter to
acknowledge
receipt of an
appeal
(continued)
WVFH review
and decision
notice
• The Member, Member’s appointed representative, or provider that filed on
the Member’s behalf can submit additional information to be considered
by the plan; and
• The Member or Member’s appointed representative has the right to
request the aid of a WVFH staff member who has not been involved in the
matter under review to assist them through the appeal process (free of
charge).
A licensed physician who has not been involved in any previous level of review or
decision making on the issue of your appeal and who has clinical experience in
treating your condition will review your appeal.
WVFH will commence its review, arrive at its decision, and issue a written decision
notice within thirty (30) days of receiving the appeal. The time frame for a decision
may be extended up to fourteen (14) days at the request of the Member, or by
WVFH if additional information is necessary and the delay is in the Member’s
interest. If WVFH extends the time frame, WVFH will send the Member a written
notice of the reason for the delay.
A written notice of the appeal decision notifying the Member, Member’s
appointed representative, or provider who filed on behalf of the member will
include the disposition of the appeal including the following:
• the result;
• the date of the resolution;
• the right and the procedure to request a State fair hearing (must be filed
within ninety (90) days from the mail date on the Appeal decision letter);
• the right to receive continuation of benefits while the hearing is pending;
• how to make a request for continuation of benefits;
• the potential Member liability for the cost of continuation benefits if the
State Fair Hearing upholds WVFH’s decision.
Expedited
appeals
The Member, Member’s representative, or health care provider with written
consent of the Member can file an Expedited Grievance orally with WVFH by
contacting Member Services at 1-855-412-8001 or in writing at:
West Virginia Family Health
Attention: MEMBER CORRESPONDENCE
P.O. Box 22250
Pittsburgh, PA 15222
Continued on next page
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3.4 MEMBER APPEALS, Continued
Expedited
appeals
(continued)
The Expedited Appeal process is provided for use in instances when the Member’s
life or health or ability to attain, maintain, or regain maximum function would be
placed in jeopardy by the delay occasioned by the standard thirty (30) day review
process. The Member’s physician must provide written certification of the need to
expedite the process. The certification must include the clinical rationale and facts
to support the physician’s opinion. If a physician certification is not received, a
WVFH physician will determine if the request is in need of expeditious resolution.
If the Member or Member’s appointed representative files an expedited appeal to
dispute a decision to terminate, suspend, or reduce a previously authorized
course of treatment that was ordered by an authorized provider where the
original period covered by the original authorization has not expired and the
Member requests an extension of benefits, the Member must continue to receive
the services if the appeal is submitted within ten (10) days from the mail date on
the written Notice of Action letter.
The benefits shall be continued or reinstated until the Member or Member’s
representative withdraws the appeal, ten (10) days after WVFH mails the
resolution of the appeal unless the Member has requested an expedited appeal
within that ten (10) day time frame, or the time period or service limits of a
previously authorized service have been met. If services are continued during the
expedited appeal process and WVFH upholds its decision to terminate, suspend,
or reduce, the member may be liable for payment of the services received
through continuity.
The expedited appeal request will be committed to writing and will be reviewed
under the same requirements as the formal grievance process previously
described with the following exceptions:
• WVFH will make reasonable efforts to provide oral notice of the disposition
of the expedited review to the Member, Member’s appointed
representative and the provider involved in the expedite within three (3)
working days of receiving the request for expedite. The three (3) working
day time frame may be extended by up to 14 days upon the Member’s
request or if WVFH shows that additional information is required and that
the delay is in the best interest of the Member. If the time frame for
resolving an expedited appeal is extended for any reason other than the
Member’s request, WVFH shall give the Member written notice of the
reason for the delay.
• It is the responsibility of the Member, the Member’s appointed
representative, or the appealing provider to submit information to WVFH
within the time constraints of the expedited appeal process.
Continued on next page
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3.4 MEMBER APPEALS, Continued
Expedited
appeals
(continued)
• WVFH will ensure that punitive action is not taken against a provider who
either requests expedited resolution of an appeal or supports a Member’s
request for an expedited review.
A written notice will follow that explains the rationale for the decision, including
any clinical rationale and the procedure for obtaining a State Fair Hearing.
State Fair
Hearing
A Member must exhaust the appeals process prior to filing a request for a State
Fair Hearing. A State Fair Hearing will be provided by the State if WVFH has
denied, terminated, or reduced services or has failed to give a Member timely
service.
A request for a State Fair Hearing can be made orally, in writing, or by completing
a Request for Hearing form at the Member’s local Department of Health and
Human Resource (DHHR) office. Members must request a State Fair Hearing
within ninety (90) days from the date on the appeal decision letter. State Fair
Hearing requests should be sent to:
Bureau for Medical Services
Office of Legal Services
350 Capitol St., Room 251
Charleston, WV 25301-3708
If the Member or Member’s appointed representative files a State Fair Hearing to
dispute a decision to terminate, suspend, or reduce a previously authorized
course of treatment that was order by an authorized provider where the original
period covered by the original authorization has not expired and the Member
requests an extension of benefits, the Member must continue to receive the
services if the request for State Fair Hearing is submitted within ten (10) days from
the mail date on the written appeal decision letter.
The benefits shall be continued or reinstated until the Member or Member’s
appointed representative withdraws the State Fair Hearing, ten (10) days after
WVFH mails the resolution of the appeal unless the Member has requested a State
fair hearing within that ten (10) day timeframe, or the time period or service limits
of a previously authorized service have been met. If services are continued during
the State Fair Hearing process and the State upholds WVFH’s decision to
terminate, suspend, or reduce, the Member may be liable for payment of the
services received through continuity.
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3.4 PROVIDER INITIATED MEMBER GRIEVANCES OR APPEALS
Overview
The Member has the right to ask any person (family, friend, relative, attorney,
provider, etc.) to act as a representative during the grievance or appeal process.
This person is referred to as the Member’s representative. If the representative is a
health care provider, the provider must secure and provide to WVFH the
Member’s written consent to do so.
If the Member is a minor or legally incompetent, the provider must submit written
consent of the parent, guardian, or legally appointed representative in order to
pursue a grievance or appeal. It is important to note that the Member may rescind
consent at any time.
Member
consent
requirements
Providers may request the Member’s written consent to appeal prior to treatment,
but it cannot be a requirement for treatment to be provided. In addition, Medicaid
Members may not be billed or balance billed for covered services at any time. The
Member’s consent is automatically rescinded if the provider fails to pursue the
grievance or appeal and the Member may continue the grievance or appeal at
that point in the process.
An acceptable consent document must contain all of the following components:
• The Member’s name;
• The Member’s address;
• The Member’s identification number;
• If the Member is a minor or legally incompetent, the name, address, and
relationship to the Member of the person who consents for the Member;
• The name, address and identification number of the provider to whom the
Member or representative is granting consent;
• The name and address of the plan to whom the Member or representative
is providing consent;
• An explanation of the specific service for which coverage was provided
and/or denied to which the consent applies.
The following statements must also be included in the consent document:
• The Member or the Member’s representative may not submit a grievance
concerning the services listed in this consent form unless the Member or
the Member’s legal representative rescinds consent in writing. The
Member or the Member’s legal representative has the right to rescind
consent at any time during the grievance or appeal process.
Continued on next page
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3.4 PROVIDER INITIATED MEMBER GRIEVANCES OR APPEALS,
Continued
Member
consent
requirements
(continued)
• The consent of the Member or the Member’s legal representative is
automatically rescinded if the provider fails to file a grievance or fails to
continue to prosecute the grievance or appeal through the second level
review process.
• The Member or the Member’s legal representative, if the Member is a
minor or is legally incompetent, has read, or has been read this consent
form, and has had it explained to his or her satisfaction. The Member or the
Member’s legal representative understands the information in the
Member’s consent form.
The document must also contain the dated signature of the Member or the
Member’s legal representative if the Member is a minor or is legally incompetent
as well as the dated signature of a witness.
The Member may rescind the consent at any time during the grievance or appeal
process. If consent is rescinded, the Member may continue the process at the
point in the process at which consent was rescinded. The Member may not file a
separate grievance or appeal. A Member who has already filed a grievance or
appeal may choose to authorize a provider to pursue the grievance or appeal
process at any point during the process. A Member’s appointed representative
carries all the rights conferred upon the Member.
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CHAPTER 4: HEALTH CARE MANAGEMENT
UNIT 1: REFERRALS
IN THIS UNIT
TOPIC
General Information
Voice Activated Referral
Paper Referrals
Referrals for Specific Services
• Out-of-Plan Referrals
• Referrals for Second Opinions
• Referrals for Surgical Second Opinions
• Specialty Care Practitioners
• Renal Dialysis Services
• Audiology and Speech Therapy
Self-Referral
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4.1 GENERAL INFORMATION
Introduction
Referrals and authorizations are necessary in order to preserve the PCP’s
gatekeeper relationship with the patient. Both processes allow West Virginia
Family Health (WVFH) to manage the care of its member population. The major
differences between referrals and authorizations are highlighted below:
• Referrals allow the PCP to approve specialty services for members on their
panel.
• Authorizations allow WVFH to confirm eligibility of the member prior to
receiving services; to assess the medical necessity and appropriateness of
care; to establish the appropriate site for care; and to identify those
members who would benefit from care management.
Referrals will be discussed in this unit. For authorization information, please see
this manual’s Chapter 4, Unit 2: Authorizations.
Self-referrals
In certain instances, members do not require a referral from the PCP to see a
Network specialty care practitioner. For the following services, members can selfrefer:
• OB/GYN Services
• Family Planning Services (Family Planning services do not have to be
rendered by a network provider)
• Dental services provided by a network dentist
• Routine vision
• Chiropractic services (an authorization must be obtained by the
chiropractic office, including the initial evaluation
• Mental health/substance abuse services
Determining
if a service
requires a
referral or
authorization
Some services, such as hospital admissions, require authorization by the WVFH
Utilization Management Department. To authorize a service, please call WVFH’s
Utilization Management Department at 1-855-412-8003.
To determine which services require a referral or authorization, please refer to
WVFH’s Quick Reference Guide for Referrals and Authorizations. This guide is also
available in this manual’s Appendix.
Continued on next page
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4.1 GENERAL INFORMATION, Continued
Referring
to Network
providers
When a PCP determines that a member requires medical services or treatment
outside of the PCP’s office, the PCP must issue a referral to a Network facility or
specialty care practitioner. If services are performed in a hospital setting, the
referral should be issued to the hospital’s provider identification number. PCPs
may not issue referrals to other PCPs.
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4.1 VOICE ACTIVATED REFERRAL
Voice
activated
referral
WVFH’s Digital Voice Assistance (DIVA) system may be used by PCPs to issue a
referral, and by specialty care practitioners and hospitals to verify and review a
referral.
To use the system, call 1-888-907-8002, and please follow the prompts, or use
the guide below for a quick reference.
Do not use this system to refer to a dental provider.
DIVA Quick
Referral Entry
Guide
IMPORTANT!
Before you
begin…
If you are a new DIVA user, we suggest for your initial try at entering a referral that
you use the detailed Referral Entry instructions below or in the DIVA Quick
Referral Entry Guide. You’ll quickly find it only takes seconds to generate a DIVA
referral. This guide is also available in this manual’s Appendix.
DIVA is only for referrals from PCPs to specialists (independent or at hospital
clinics). Authorization is still required for some services. Specialists and
hospitals may only review referrals.
To issue a Referral, you will need:
• Provider ID Number (“Practice Number”)
• Member ID Number
• Specialist/Hospital Provider ID Number (“Practice Number”) for th referred
provider
• Type of referral and number of visits
The system will provide a referral number and provides an option to fax a
confirmation of the referral information to the specialist/hospital.
Continued on next page
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4.1 VOICE ACTIVATED REFERRAL, Continued
To issue a
referral
After dialing into DIVA at 1-888-907-8002, first Press 1 to retrieve information
regarding West Virginia members, and then Press 2 to enter a new referral. Follow
the prompts below:
STEP
ACTION
1
Provider Identification Number?
Enter your group provider number.
Member Identification Number?
Enter the member’s 8 digit ID number (as it appears on the member’s
ID card).
Specialist/Hospital Provider Identification Number?
Enter the group provider number of the specialist hospital to which
you wish to refer the member. Finish by pressing the # key.
(pause) Verification of Identification Numbers
Type of Referral
o Press 1 to enter a general referral for three visits within the next
90 days.
o Press 2 to enter a referral for allergy or pain management services
for nine visits within the next 90 day.
2
3
4
5
Please enter the beginning date for the referral. Referrals can be backdated 30 calendar days. Enter the two digit month, the two digit day,
and the four digit year. Press 1 if the repeated date is correct. Press 2 if
the repeated date is incorrect. Press the * key to begin again.
6
Save Referral?
o Press 1 to save the referral (wait for referral ID number).
o Press 2 to discard the referral.
ADDITIONAL INSTRUCTIONS:
• Press 1 to repeat the referral number
• Press 2 to enter a new referral for the same PCP
• Press 3 to enter a new referral for a different PCP
• Press 4 to fax a referral (see options below*)
• Press 5 to return to the main menu
• Press 6 if you are finished
• Press 9 to hear this menu again
• Press 0 to be connected to a Provider Services Representative
*If you chose 4: To fax a referral, choose one of the following options:
o Press 1 to send a fax to the PCP only (see options below**)
o Press 2 to send a fax to the specialist/hospital only (see options below**)
Continued on next page
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4.1 VOICE ACTIVATED REFERRAL, Continued
To issue a
referral
(continued)
o
o
o
o
Press 3 to send a fax to both the PCP (see options below**)
Press 4 to return to the main menu without sending a fax
Press 9 to hear this menu again
Press # to return to the previous menu
**If you chose 1, 2, or 3: To send a fax, choose one of the following options:
 Press 1 to use the fax number stored in the database
 Press 2 to enter a fax number (allows you to enter any fax number)
 Press # to return to the previous menu
To verify
or review
a referral
After dialing into DIVA at 1-888-907-8002, first Press 1 to retrieve information
regarding West Virginia members, and then Press 3 to review an existing referral.
Follow the prompts below:
STEP
1
2
3
4
ACTION
Provider Type?
o Press 1 if you wish to enter a PCP ID Number
o Press 2 if you wish to enter a specialist/hospital ID Number
Provider Number?
Enter your group provider identification number.
Member ID Number?
Enter the member’s 8-digit WVFH ID number (as it appears on the
member’s ID card).
(pause) Referral Information
If there is a match, the following information will be provided:
PCP ID Number; Member ID Number; Specialist/Hospital ID Number;
Referral Case Number; Effective Date; Expiration Date; Number of
Visits Approved
Playback Options:
• Press 1 to play the referral information again
• Press 2 to check for subsequent referrals
• Press 3 to check for a referral using the same PCP
• Press 4 to check for a referral using a different PCP or specialist
• Press 5 to fax a list of reviewed referrals (see options below*)
• Press 6 to return to the main menu
• Press 7 to exit
• Press 9 to hear this menu again
• Press 0 to speak with a Provider Services Representative
Continued on next page
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4.1 VOICE ACTIVATED REFERRAL, Continued
To verify
or review
a referral
(continued)
*If you chose 5: To fax a referral, choose one of the following options:
o Press 1 to send a fax to the PCP only (see options below**)
o Press 2 to send a fax to the specialist/hospital only (see options below**)
o Press 3 to send a fax to both the PCP (see options below**)
o Press 4 to return to the main menu without sending a fax
o Press 9 to hear this menu again
o Press # to return to the previous menu
PLEASE NOTE: The number of the practitioner will be reviewed via the
automated system if one is found. Please assure that this is the number
that you wish to send the fax to. See additional options below for
choosing the default fax or entering a new fax number.
**If you chose 1, 2, or 3: To send a fax, choose one of the following options:
 Press 1 to use the fax number stored in the database
 Press 2 to enter a fax number (allows you to enter any fax number
 Press # to return to the previous menu
NOTE: You may press “0” (zero) followed by the “#” sign at any time to speak to a
Provider Services Representative.
If a referral is found that matches the information entered, the system will provide
the following information:
• Provider ID Number
• Member ID Number
• Referral Case Number
• Effective Date and Expiration Date
• Number of Visits Approved
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4.1 PAPER REFERRALS
Overview
WVFH understands that there may be instances when a PCP is unable to use DIVA.
A downloadable version of the PCP Referral Form is available in the Appendix of
this manual and also on the WVFH website at www.wvfh.com. Each time a form is
downloaded, it is given a unique referral number.
For claims payment purposes, each referral you issue requires a NEW form to be
downloaded and printed. Just print, complete, and mail to the address on the
form.
Prior to
completing
the form
Please use the following procedure prior to completing your downloaded paper
referral form:
1. Check your practice’s Member List or call WVFH’s Digital Voice Assistant to
verify the member’s eligibility.
2. Assure that the needed service does not require an authorization from
WVFH.
3. Select a Network specialist or facility appropriate for the member’s medical
needs from WVFH’s Provider On-line Directory. If an appropriate provider is
not listed in the Directory, please call Provider Services for assistance.
Instructions for
completing the
paper referral
form
Once a Network provider is selected from WVFH’s On-Line Directory, the primary
care practitioner’s (PCP) office completes the following sections of the Referral
Form:
1. Primary Care Information:
a. Complete the primary care practitioner (PCP) Name, Practice Address,
and Telephone Number.
b. Fill in the Practice’s 7-digit WVFH Provider ID Number.
2. Patient Information
a. Complete the Patient’s Name.
b. Fill in the Member’s 8-digit WVFH Member ID Number. Complete the
diagnosis and/or complaint field being as specific as possible. The
diagnosis can be an ICD-9 (preferred) (or its replacement) code or a
written description.
3. Specialty Provider or Facility Information
a. SPECIALTY CARE PROVIDER: Complete the Specialist group name and
WVFH Provider ID Number for services rendered at office site only.
b. FACILITY PROVIDER: Complete the Facility name and WVFH Facility ID
Number for services rendered at outpatient facility to allow both
facility and practitioner services to be covered.
Continued on next page
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4.1 PAPER REFERRALS, Continued
Instructions for
completing the
paper referral
form
(continued)
4. Referral Services
If you are referring a member for services that DO NOT REQUIRE
authorization, you can check the appropriate service and specify additional
information as requested on the form.
5. PCP Signature
The paper referral form must be signed by the member’s PCP. If an office
staff member completes the referral, the staff member must place their
initials after the practitioner’s stamp or signature. AN UNSIGNED PAPER
REFERRAL FORM IS NOT VALID.
6. Referral Date
The Referral Form must be dated. If the Referral Form is not dated, WVFH
will date according to receipt date at the claim office. Payment for referral
and authorized services is contingent upon the patient being an enrolled
WVFH member at the time of the service.
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4.1 REFERRALS FOR SPECIFIC SERVICES
Out-of-plan
referrals
Occasionally, a member may need to see a specialty care practitioner outside of
WVFH’s provider network. When the need for out-of-plan services arises, the PCP
must contact WVFH’s Utilization Management Department to obtain an
authorization. The Utilization Management Department will review the request
and make arrangements for the member to receive the necessary medical services
with a specialty care practitioner in collaboration with the recommendations of
the PCP. Every effort will be made to locate a specialty care practitioner within an
accessible distance to the member.
Referrals
for second
opinions
WVFH ensures member access to second opinions. Second opinions may be
requested by WVFH, the member, or the PCP. WVFH will provide for a second
opinion from a qualified health care provider within the network, or arrange for
the member to obtain one outside the network, at no cost to the member. The
second opinion specialist must not be in the same practice as the attending
physician and must be a Network provider of WVFH. Out of network referrals may
be authorized when no Network provider is accessible to the member or when no
Network provider can meet the member’s needs.
Referrals
for second
surgical
opinions
Second surgical opinions may be requested by WVFH, the member, or the PCP.
When requesting a second surgical opinion consultation, WVFH recommends that
you issue a referral to a consulting practitioner who is in a practice other than that
of the attending practitioner, or the practitioner who rendered the first opinion
and possesses a different tax identification number than the attending
practitioner.
Specialty care
practitioners
When a WVFH member schedules an appointment with a specialist, the office
should remind the member that a referral from the PCP is needed in order to
receive treatment from the specialist, with the exception of a self-referred benefit.
Specialty care practitioners should verify the existence of a valid referral through
the DIVA System by calling 1-888-907-8002 prior to providing treatment.
If a paper referral form is utilized, the specialty care practitioner must review the
referral form to verify that the form is valid. A valid form is signed by the PCP and
has a referral date within the last ninety (90) days.
If other services are needed in addition to those authorized by the PCP, a
treatment plan must be completed and forwarded to the PCP for authorization.
The PCP can then issue additional referrals based upon the recommendations of
the specialty care practitioner.
Continued on next page
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4.1 REFERRALS FOR SPECIFIC SERVICES, Continued
Specialty care
practitioners
(continued)
Since specialists cannot refer members to other specialists, the PCP must refer the
member to another specialist. If a specialist recommends that the patient should
be seen by another specialty care practitioner, the specialist must contact the PCP,
and the PCP may then examine the patient and/or review the consult report prior
to referring the patient to another specialist.
The only exception to this is for neonatologists who may issue a referral to other
Network hospitals and/or specialists for babies discharged from the NICU who
require service before seeing their PCP. Referrals should be issued under the
baby’s WVFH ID Number. If the baby does not have an ID Number, the practitioner
should call WVFH’s Utilization Management Department for authorization.
In unusual situations, the specialist or PCP may contact WVFH’s Utilization
Management Department at 1-855-412-8003.
Renal dialysis
services
If home dialysis services are necessary, an authorization from WVFH’s Utilization
Management Department is needed.
Audiology and WVFH members under the age of 21 are eligible to receive audiological services
speech therapy including hearing aids and ear molds. The member’s primary care practitioner
(PCP) must issue a referral for audiological services to a Network, licensed
practitioner, licensed audiologist or an outpatient hospital clinic. Prior to
dispensing aids and/or ear molds, the audiological practitioner must obtain
authorization through the ordering practitioner from WVFH’s Utilization
Management Department. Reimbursement rates for hearing aids, ear molds,
repair parts and any specialty items not covered on the Medicaid Fee Schedule
should be negotiated at the time of authorization, prior to rendering services.
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4.1 SELF-REFERRAL
Introduction
West Virginia Family Health (WVFH) members may refer themselves for the types
of care listed below.
Dental
WVFH members obtain most of their health care services either directly from or
upon referral by their Primary Care Physician (PCP), except for services available on
a self-referral basis. Dental services are included as a self-referral service.
Therefore, a referral from a WVFH member’s PCP is not necessary for the member
to seek care from a network dental provider or specialist.
Certain oral surgery procedures, such as removal of partial or total bony impacted
wisdom teeth and procedures which involve cutting of the jaw, are covered by
WVFH through Scion’s panel of network oral surgery providers. Members
requiring these services should be referred by their primary care dentist to a
network oral surgeon. The primary care dentist may need to provide x-rays or
other clinical information to facilitate the referral.
Procedures performed in the oral surgeon’s office do not require prior
authorization. If it is determined that the oral surgery treatment can only safely be
performed in a Short Procedure Unit (SPU) or Ambulatory Surgical Center (ASC)
facility, the dental provider must contact Scion Dental for authorization prior to
rendering treatment.
Dental
specialty
referral
WVFH members may not self-refer for specialty dental care. Any WVFH
participating dentist may refer a member to another participating dentist for
specialty care services that are covered by following these guidelines:
• The participating dental provider may refer a member to a participating
specialist without a written referral.
• Please provide the member with written or verbal dental care
recommendations.
• If a specialist is not available in a member’s area, please contact the Scion
Dental 1-855-434-9237.
Continued on next page
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4.1 SELF-REFERRAL, Continued
Dental
specialty care
providers
It is recommended that a general dentist evaluate a member before scheduling an
appointment with a specialty dental care provider. However, if time does not
permit a general dental evaluation, such as in the case of an emergency, the
member may seek and receive treatment by a dentist specialist.
In the case of an emergency, dental specialty care providers may provide services
necessary to treat and stabilize the member’s condition without a referral from a
general dentist. Please contact the Scion Dental at 1-855-434-9237 for a listing
of participating specialty dental care providers.
Emergency
Members are informed through the Member Handbook how and when to utilize
emergency services.
Eye
examinations
WVFH members who have covered vision benefits may self-refer to any Davis
Vision Network provider for a routine eye exam. Corrective lenses and frames may
be obtained through any Davis Vision Network optician, optometrist, or
ophthalmologist. There is no need for the PCP to issue a referral.
Should the member require additional medical services, rendered by a Davis
Vision Network ophthalmologist or optometrist, the member will require a referral
from the PCP.
Behavioral
health/
substance
abuse
Members are permitted to self-refer for behavioral health and substance abuse
services. Please refer to the Quick Reference section of this manual for the
telephone numbers for members to call.
OB/GYN or
family
planning
services
Female WVFH members may self-refer to any Network OB/GYN for any condition,
not just for an annual exam or suspected pregnancy. When a member self-refers
to the OB/GYN’s office, the OB/GYN’s office is required to contact WVFH to verify
eligibility of the member. WVFH members may also self-refer for family planning
services.
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CHAPTER 4: HEALTH CARE MANAGEMENT
UNIT 2: AUTHORIZATIONS
IN THIS UNIT
TOPIC
SEE PAGE
General Information
• Criteria Used for Assessing Medical Appropriateness
• Review/Determination of Medical Necessity
• Utilization Management Contact Information
Services Requiring Authorization
Requesting an Authorization
• Information Needed When Requesting an Authorization
• Decision Time Frame
• Expedited Authorization Requests
• Medical Necessity Criteria
• Post-Service Requests
Chiropractic Services
Durable Medical Equipment
Skilled Nursing Facility
Physical/Occupational/Speech Therapy
Rehabilitation Services
• Extended Care in a Non-Hospital Facility
• Cardiac and Pulmonary Rehabilitation Services
Home Health Care
Hospice Services
Pharmacy Services
Diabetic Services
New Technology
2
2
2
3
4
5
5
5
6
6
7
8
9
11
12
13
13
13
14
15
16
17
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4.2 GENERAL INFORMATION
Introduction
Referrals and Authorizations are necessary in order to preserve the PCP’s
gatekeeper relationship with the patient. Both processes allow West Virginia
Family Health (WVFH) to manage the care of its member population. The major
differences between referrals and authorizations are highlighted below:
• Referrals allow the PCP to approve specialty services for members on their
panel.
• Authorizations allow WVFH to confirm eligibility of the member prior to
receiving services; to assess the medical necessity and appropriateness of
care; to establish the appropriate site for care; and to identify those
members who would benefit from care management.
Authorizations will be discussed in this unit. For referral information, please see
this manual’s Chapter 4, Unit 1: Referrals.
Criteria used for
assessing
medical
appropriateness
Review/
determination
of medical
necessity
West Virginia Family Health’s (WVFH’s) Utilization Management Department
assesses the medical appropriateness of services using McKesson’s Interqual®
Procedure Criteria and the Department of Health and Human Resources, Bureau
for Medical Services (BMS) definition of medical necessity when authorizing the
delivery of health care services to plan members.
The definition of medical necessity is a determination that items or services
furnished or to be furnished to a patient are reasonable and necessary for the
diagnosis or treatment of illness or injury, to improve the functioning of a
malformed body member, for the prevention of illness, or to achieve ageappropriate growth and development.
Determination of Medical Necessity for covered care and services, whether made
on a Prior Authorization, Concurrent Review, Retrospective Review, or exception
basis, must be documented in writing. The determination is based on medical
information provided by the Member, the Member’s family/caretaker and the PCP,
as well as any other providers, programs, or agencies that have evaluated the
Member.
All such determinations must be made by qualified and trained health care
providers. A health care provider who makes such determinations of Medical
Necessity is not considered to be providing a health care service under this
Provider Manual.
Continued on next page
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4.2 GENERAL INFORMATION, Continued
Review/
determination
of medical
necessity
(continued)
WVFH requires that all reviewers make utilization management decisions based
only on the medical necessity and appropriateness of care and the availability of
coverage under our benefit contracts. We do not reward anyone conducting
utilization review for issuing denials of coverage. We do not use financial
incentives to encourage denials or other decisions that could result in
underutilization of needed services or otherwise compromise members’ health.
Decision
time frame
WVFH must make authorization decisions and provide notice as expeditiously as
required by the enrollee’s health condition and no later than seven (7) calendar
days of receiving the request for service for the purposes of standard
authorization decisions. This seven (7) calendar day period may be extended up to
seven (7) additional calendar days upon request of the enrollee or provider, or if
WVFH justifies to the Bureau of Medical Services (BMS) in advance and in writing
that the enrollee will benefit from such extension.
Utilization
Management
contact
information
The Utilization Management Department is committed to assuring prompt,
efficient delivery of healthcare services and to monitor quality of care provided to
WVFH members. The Utilization Management Department can be contacted at
1-855-412-8003 between the hours of 8:30 AM and 4:30 PM, Monday through
Friday. The following options can be used to reach WVFH’s Utilization Management
Department for specific information:
REASON FOR CALL
OPTION
Calls for DME, Therapy, or Chiropractic Services
Calls for Emergency Inpatient Admissions, Concurrent Review,
Home Health Updates, or IV Infusion
Option 3
Option 4
When calling before or after operating hours or on holidays, practitioners are asked
to leave a voicemail message and a Utilization Management Representative will
return the call the next business day.
Urgent requests, pharmacy requests, and home health requests requiring a visit
when the WVFH Utilization Management Department is closed, or
urgent/emergency inpatient place of service admission called in after hours are
directed to call 1-855-412-8003. A WVFH Medical Director is available for review of
these requests when necessary.
For urgent or emergency situations, WVFH requires that the practitioner notify the
plan within forty-eight (48) hours or two (2) business days of rendering the service.
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4.2 SERVICES REQUIRING AUTHORIZATION
List of services
requiring
authorization
The following services require an authorization from WVFH:
• All Hospital Admissions
• Select Outpatient Surgical Procedures:
 Bariatric Surgery/Stapling

 Breast Reduction

 Carpal Tunnel Surgery

 Hysterectomy

 Panniculectomy

 Tubal Ligations

 Orthoptics/Visual Training

 Sterilizations

 Genital Reconstruction

Removal of Breast Implant
Rhinoplasty
Spinal Neuro Stimulator Services
TMJ Surgery
Varicose Vein
Private Duty Nursing
Abortions
Transplants/Implants
Blepharoplasty
• Speech, Occupational, or Physical Therapies (Members can be referred to
any WVFH Network hospital for speech, occupational, or physical therapy
sessions)
• Outpatient Cardiac Rehabilitation and Pulmonary Rehabilitation (Members
can be referred to any WVFH Network provider for rehabilitation sessions)
• Referrals for specialty care requiring greater than three visits, unless
otherwise noted
• All services to be provided by an out-of-network practitioner/provider
(including durable medical equipment and home health)
• Durable Medical Equipment items $500 or greater or not covered on the
Medicaid Fee Schedule regardless of cost
• All Durable Medical Equipment rentals $500 or greater monthly
• Home Health Care
• All non-covered services
• Hospice
• Hearing aids, ear molds, dispensing fees, as well as hearing aid repair services
• Skilled Nursing Facility Admissions
• Rehabilitation Hospital Admissions
• Chiropractic Services – All visits, including the initial visit
• Dental Services (see page 52 in Scion Dental Provider Manual available on the
WVFH website at www.wvfh.com)
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4.2 REQUESTING AN AUTHORIZATION
Overview
Authorization is the responsibility of the admitting practitioner or ordering
provider and can be obtained by calling WVFH’s Utilization Management
Department at 1-855-412-8003.
If a service requires authorization and is being requested by a Network specialist,
the specialist’s office must call WVFH to authorize the service. Hospitals may verify
authorization by calling the WVFH Utilization Management Department. Physical,
occupational, or speech therapy requires authorization by the ordering
practitioner or the primary care practitioner (PCP).
Information
needed when
requesting an
authorization
The following information is needed to authorize a service. Please have this
information available before placing a call to the Utilization Management
Department:
1. Member Name
2. Member’s 8-digit WVFH ID Number
3. Diagnosis (ICD-9 Code or precise terminology) (or its replacement)
4. Procedure Code (CPT-4, HCPCS, or MA Coding) or billing codes for durable
medical equipment requests
5. Treatment Plan
6. Date of Service
7. Name of Admitting/Treating Practitioner
8. Name of the Practitioner/Provider requesting the authorized treatment
9. Provider of Service 7-digit WVFH ID Number
10. History of the current illness and treatments
11. Any other pertinent clinical information
When a call is received, the above information will be reviewed, and the member’s
eligibility verified. However, since a member’s eligibility may change prior to the
anticipated date of service, eligibility must be verified on the date of service.
Decision
time frame
WVFH must make authorization decisions and provide notice as expeditiously as
required by the member’s health condition, and no later than seven (7) calendar
days of receiving the request for service for the purposes of standard
authorization decisions. This seven (7) calendar day period may be extended up to
seven (7) additional calendar days upon request of the enrollee or provider, or if
WVFH justifies to BMS in writing that the member will benefit from such
extension.
Continued on next page
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4.2 REQUESTING AN AUTHORIZATION, Continued
Expedited
authorization
requests
WVFH must provide an expedited authorization for services when the provider
indicates that the standard time frame could seriously jeopardize the member’s
life or health or ability to attain, maintain, or regain maximum function. WVFH
must make the expedited authorization decision and provide notice to the
member as expeditiously as the member’s health condition requires, but no later
than three (3) business days after receipt of the request for service authorization.
This three (3) business day period may be extended up to five (5) additional
business days upon request of the enrollee or provider, or if WVFH justifies to BMS
in writing that the member will benefit from such extension.
WVFH must provide thirty (30) days’ notice to providers before implementing
changes to policies and procedures affecting the service authorization process.
However, in the case of suspected fraud, waste, or abuse by a single provider,
WVFH may implement changes to policies and procedures affecting the service
authorization process without the required notice period.
Medical
necessity
criteria
The definition of Medical Necessity is as follows: A service or benefit is medically
necessary if it is compensable under the Medicaid Program and a determination
that items or services furnished or to be furnished to a patient are reasonable and
necessary for the diagnosis or treatment of illness or injury, to improve the
functioning of a malformed body member, for the prevention of illness, or to
achieve age-appropriate growth and development.
Medical Necessity criteria are established guidelines to be applied by nonphysician, licensed professionals to authorize services as medically necessary and
at the appropriate level of care.
If an authorized service is not able to be approved as proposed by the
practitioner, alternate programs such as home health care, rehabilitation, or
additional outpatient services will be suggested to the practitioner by the UM
staff. If an agreement cannot be reached between the practitioner and the
Utilization Management staff, the case will be referred to WVFH’s Medical Director
for review. A practitioner may appeal the decision within ninety (90) days of the
date of the denial notice. Please refer to this manual’s Chapter 3, Unit 4: Member
and Provider Disputes for the process to appeal a decision.
The determination is based on medical information provided by the member, the
member’s family/caretaker and the primary care practitioner (PCP), as well as any
other practitioner/providers, programs, agencies that have evaluated the
member. All such determination must be made by qualified and trained
practitioners/providers.
Continued on next page
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4.2 REQUESTING AN AUTHORIZATION, Continued
Post-service
requests
Any service rendered by a Network Provider without an authorization will be
reviewed for medical necessity within 180 days from the date of service. Submit
records and a cover letter requesting a retrospective review to:
West Virginia Family Health
Attention: Medical Review
P.O. Box 22278
Pittsburgh, PA 15222
Retrospective reviews will be completed within 60 days of the request. The
decision is final and binding.
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4.2 CHIROPRACTIC SERVICES
Requesting
authorization
Any Network practitioner may request authorization for chiropractic services by
calling WVFH’s Utilization Management Department at 1-855-412-8003, Option #3.
All visits, including the initial visit, require authorization by WVFH and must be
medically necessary. Member eligibility must be verified prior to rendering services
by calling DIVA at 1-888-907-8002.
Members may self-refer for chiropractic services; however, the chiropractic office
must call WVFH for authorization including the initial evaluation.
Services
The only therapy WVFH will authorize is a simple manipulation for an acute spinal
problem. Other requests will be referred to the Medical Director for review and
determination. Additionally, one chiropractic evaluation will be authorized per
course of treatment. Requests for children under the age of 16 are referred to
WVFH’s Medical Director for approval. Only one visit per day can be authorized.
Radiological
services
Network chiropractors may render radiological services in the office. WVFH only
reimburses chiropractors for the professional and technical components of
covered diagnostic radiology services (CPT 72010-72120) if the chiropractor
performs both parts of the procedure. Only one interpretation of an x-ray will be
reimbursed. X-rays must be taken on certified radiology equipment that complies
with all State and Federal requirements. Members requiring radiological services
beyond the services listed above, such as a CT scan or MRI should be referred back
to PCP.
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4.2 DURABLE MEDICAL EQUIPMENT
Introduction
WVFH members are eligible to receive any covered and medically necessary
durable medical equipment (DME) needed for home health care.
Guidelines
When ordering DME, these procedures must be followed:
• If the cost of a single item or multiple quantities of a single item is $500or
greater as reimbursed by Medical Assistance, the ordering
practitioner/provider must obtain authorization from the Utilization
Management Department. A referral from the PCP is not required, but a
written prescription and WVFH authorization are necessary to obtain the
item.
• Rental equipment must be authorized if the monthly rental cost is $500or
greater.
• Covered items under $500 can be obtained from a Network durable
medical equipment provider with a prescription from the ordering
practitioner/provider. A referral from the PCP and WVFH authorization is
not required. Provider Services or Utilization Management can direct
practitioners to a contracted vendor to supply durable medical equipment.
DME vendors are also listed in the WVFH On-Line Provider Directory at
www.wvfh.com. A written prescription is required to obtain the item.
• Any item not covered by Medicaid, regardless of price, requires
authorization by the Utilization Management Department.
• Regardless of price, when a miscellaneous code is requested, an
authorization from WVFH’s Utilization Management Department is
required.
• Due to frequent interruptions of Medicaid coverage, WVFH strongly
recommends that all providers verify eligibility if the need for an item or
service extends beyond the calendar month in which the authorization
was given.
• All medical supplies including wound care, ostomy, enteral products,
diapers, and incontinence products must be obtained through a
contracted DME vendor as opposed to a Network pharmacy.
• Oral enterals must be obtained through a Network DME provider. Based on
the cost of the product ordered, an authorization from WVFH’s Utilization
Management Department may be necessary if the product is $500 or
greater. Please do not direct members to retail pharmacies such as Rite Aid,
etc. for these services.
Continued on next page
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4.2 DURABLE MEDICAL EQUIPMENT, Continued
Guidelines
(continued)
Information
needed when
ordering DME
• When ordering DME, practitioners can contact a Network DME provider to
receive the appropriate billing code(s) before calling WVFH’s Utilization
Management Department. Or practitioners can call and request WVFH’s
staff work directly with a Network DME provider to obtain the appropriate
billing code and cost. If you need an updated list of Network providers,
please call WVFH’s Provider Services Department at 1-855-412-8002, or
access the On-Line Provider Directory at www.wvfh.com.
• DME provided by non-Network providers requires an authorization from
the WVFH Utilization Management Department.
• Incontinence items will be covered by WVFH without requesting an EOB
from any other plan; however, if the billed charge is $500 or greater, and/or
a miscellaneous code is used to request the supply, a Utilization
Management authorization will be required according to plan guidelines.
Any services provided by non-Network providers always require an
authorization.
The following information will provide assistance to offices when ordering DME
services:
1. Patient Name, WVFH ID Number, Prior Authorization Number (If
Applicable)
2. DME Vendor/Provider Number
3. Ordering Practitioner/Provider
4. Diagnosis
5. Name of Requested Equipment, Medicaid Fee Schedule Code, Cost
6. Is this a Purchase or a Rental Request?
7. Amount of Items Requested—Over What Period of Time (if requesting
rental)
8. Clinical Information to Support the Request
To obtain approval for durable medical equipment, please call WVFH’s Utilization
Management Department at 1-855-412-8003.
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4.2 SKILLED NURSING FACILITY
Skilled nursing
facility
admissions
Should a member be in need of admission to a nursing facility, the primary care
practitioner (PCP), attending practitioner, hospital Utilization Review Department,
or the nursing facility should contact the WVFH Utilization Management
Department at 1-855-412-8003.
WVFH will coordinate the necessary arrangements between the PCP and the
nursing facility to provide the member with continuity and coordination of care.
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4.2 PHYSICAL/OCCUPATIONAL/SPEECH THERAPY
Policy
All physical therapy, occupational therapy, and speech therapy require an
authorization from WVFH’s Utilization Management Department. The ordering
provider of the therapy must contact WVFH’s Durable Medical
Equipment/Therapy Team to obtain the initial authorization.
When a physical, occupational, or speech therapy provider has a request for
continuation of therapy services, WVFH will accept a faxed copy of the
prescription signed by the ordering Network practitioner in lieu of a telephone
call from the Network practitioner.
Authorization
process
The following process must be observed:
1. The therapy provider must first call WVFH to request continuation of
therapy services before faxing the prescription (blind faxes will not be
accepted.) During this telephone call, the therapy provider will receive
information identifying which staff member’s attention the fax should be
sent to.
2. The therapy provider will fax to WVFH the signed prescription and the
current progress notes, plan of treatment, and goals, which support the
medical necessity of the therapy services.
3. The therapy provider will be called back when the request for therapy
services is approved.
4. When the request results in a denial, the current appeal process remains
unchanged.
When the therapy provider does not have a signed prescription, the ordering
practitioner must notify WVFH of the request for continued services.
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4.2 REHABILITATION SERVICES
Extended
care in a
non-hospital
facility
Should a member require extended care in a non-hospital facility for rehabilitation
purposes, the PCP, attending practitioner, hospital, or rehabilitation facility should
call the WVFH Utilization Management Department at 1-855-412-8003. The
Utilization Management Department will provide assistance in appropriate
placement thus ensuring continuity and coordination of care.
Cardiac and
pulmonary
rehabilitation
services
All cardiac and pulmonary rehabilitation services require an authorization from
WVFH’s Utilization Management Department.
The ordering provider of the treatment must contact WVFH’s Utilization
Management Department at 1-855-412-8003, Option #3, to obtain the initial
authorization.
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4.2 HOME HEALTH CARE
Overview
WVFH encourages the use of home-based services as an alternative to
hospitalization when medically appropriate in order to:
• Allow for timely and appropriate discharge from the hospital.
• Avoid unnecessary admissions of members who could effectively be
treated at home.
• Permit members to receive care in greater comfort due to familiar
surroundings.
Home-based
services
Home-based services may include, but are not limited to the following type of
services:
•
•
•
•
•
Skilled Nursing
Speech Therapy
Hospice
Home Health Aid
Physical Therapy
•
•
•
•
•
IV Therapy
Infant Care
Occupational Therapy
High-Risk Pregnancy
Social Services
Authorization
required for all
home-based
services
Authorization is required for all home-based services. The ordering practitioner is
responsible for obtaining authorization. Please do not call the home health care
provider directly.
Private duty
nursing
services
WVFH’s Care Management Department coordinates medically necessary private
duty nursing services with the ordering practitioner and the home health care
provider. The Care Management Department can be reached at 1-855-412-8004.
Non-private
duty home
health care
needs
WVFH’s Utilization Management Department coordinates medically necessary
non-private duty home health care needs with the ordering practitioner and the
home healthcare provider. Please call WVFH’s Utilization Management
Department at 1-855-412-8003.
Billing
WVFH cannot accept bills in half-hour increments. Providers must bill in whole
hours.
Due to frequent interruptions of Medicaid coverage, WVFH strongly recommends
verification of eligibility if the need for an item or service extends beyond to the
calendar month in which the authorization was given.
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4.2 HOSPICE SERVICES
WVFH
coordinates
hospice
services
Should a member be in need of hospice care, the PCP, attending physician,
hospital Utilization Review Department, or hospice agency should contact WVFH’s
Utilization Management Department at 1-855-412-8003. WVFH will coordinate
the necessary arrangements between the PCP and the hospice provider in order
to assure continuity and coordination of care.
Due to frequent interruptions of Medicaid coverage, WVFH strongly recommends
verification of eligibility if the need for an item or service extends beyond the
calendar month in which the authorization was given.
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4.2 PHARMACY SERVICES
Non-formulary
exception
review process
WVFH allows access to all non-formulary drugs, other than those excluded by the
Department of Health and Human Resources (“DHHR”), Bureau for Medical Services
(“BMS”) program, through the exception review process.
If changing to a formulary medication is not medically advisable for a member, a
practitioner must initiate a request for non-formulary drug coverage by faxing the
WVFH Medicaid Drug Exception Form to 1-855-430-9849 during normal business
hours, or by calling 1-855-412-8001 during off-hours and weekends. Practitioners
should assure that all information on the form is available when calling.
This form is also available in this manual’s Appendix and on WVFH’s website at
www.wvfh.com. The form may be photocopied. You can also request a copy of the
form by calling 1-855-412-8005.
All requests for exception will receive a response within 24 hours. In the event a
decision has not been made in 24 hours, WVFH will authorize a temporary supply
of the non-formulary medication.
For new therapies, the pharmacist should call WVFH to obtain an authorization to
dispense up to a 72-hour supply of the non-formulary medication. For medications
taken on an ongoing basis, a 15-day supply of the non-formulary medication will
be dispensed, pending the final determination of the request.
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4.2 DIABETIC SERVICES
Preferred
Diabetic
Supply List
West Virginia Medicaid has developed a “Preferred Diabetic Supply List.” For
details on the preferred product supply list, along with the meters which will be
supplied by Abbott Diabetes Care and Bayer Health Care, please visit the WVFH
website at www.wvfh.com for more details – select the Members tab, and then
Benefits & Services.
West Virginia Medicaid will no longer pay for diabetes meters. Information for
billing meters is included.
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4.2 NEW TECHNOLOGY
Requires
Medical
Director
review/
authorization
Any new technology identified during the Utilization Management review
process, and requiring authorization for implementation of the new technology,
will be forwarded to the Medical Director for authorization. If there is a question
about the appropriate governmental agency approval of the technology, the
Medical Director will investigate the status of the technology with the agency,
consult appropriate specialists related to the new technology, and/or utilize the
contracted services of Hayes, Inc. for information related to the new technology.
If the technology has not been approved by appropriate governmental regulatory
bodies, the Medical Director will discuss the need for the specifically requested
technology with the primary care practitioner (PCP) and will consult with a
Network specialist from the WVFH expert panel regarding the use of the new
technology.
If it is determined that no other approved technology is available and/or the
Medical Director and consultants feel that the possibility for a positive outcome
would be achieved with the use of the new technology, approval may be given
with the stipulation that the provider obtain the necessary signatures from the
member needed for any investigational treatment/procedures.
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CHAPTER 4: HEALTH CARE MANAGEMENT
UNIT 3: CARE MANAGEMENT
IN THIS UNIT
TOPIC
SEE PAGE
Lifestyle Management Programs Overview
• Maternity Program
• Asthma Program
• Diabetes Program
• Cardiac Program
• Chronic Obstructive Pulmonary Disease (COPD) Program
Special Needs Care Management
Complex Care Management
2
3
4
5
6
7
8
9
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4.3 LIFESTYLE MANAGEMENT PROGRAMS OVERVIEW
Lifestyle
management
programs
West Virginia Family Health (WVFH) wants members to live happy, healthy lives.
Lifestyle management programs are offered to help WVFH members stay well and
also manage any conditions they may have.
Lifestyle management programs offered to WVFH members include the following:
• Maternity Program
• Asthma Program
• Diabetes Program
• Cardiac Program
• Chronic Obstructive Pulmonary Disease (COPD) Program
For program details, please see the applicable sections of this unit.
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4.3 MATERNITY PROGRAM
Program
overview
The Maternity Program offers maternity care coordination to improve the
frequency of prenatal and postpartum care to reduce the incidence of low birth
weight, pre-term deliveries and NICU admissions. This is a population-based
program directed toward improving outcomes for all pregnant members. Specific
interventions are designed to identify and prospectively intervene with members
at high risk for adverse pregnancy outcomes.
All identified pregnant WVFH members are automatically enrolled once we
identify them with one of the high risk maternity conditions via the West Virginia
Prenatal Risk Screening Instrument (PRSI). Maternity Care Managers telephonically
contact these members. Members are able to opt-out if they choose.
Membership in the Maternity Program is voluntary. If at any time your patients
wish to stop participating in the program, they only need to call.
Member
benefits
and support
The program will provide the following member benefits and support:
• Patient education
• Prenatal educational packet mailed to all identified pregnant members
• Home care and DME needs are coordinated through the WVFH Care
Manager
• Information on smoking with referral to the state Quitline
• Member newsletter with related maternity articles
• Maternity Program information is available via the WVFH website
• Prenatal Reward Program
Provider
benefits
and support
Provider benefits and support include:
• Support from our nurses and other health care staff to ensure that your
patients understand how to best manage their condition and self-evaluate
their health status. Health education information mailed to all identified
pregnant members.
• Telephonic care management and coordination of care for high risk
patients.
• A bonus payment to PCPs and OB/GYNs for rendering initial prenatal visit
within the first trimester.
FOR MORE
INFORMATION
For more information or to refer a patient to the Maternity Program, please call
1- 855-412-8004.
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4.3 ASTHMA PROGRAM
Program
overview
The WVFH Asthma Program emphasizes patient education, self-management,
practitioner education and support to increase appropriate medication use and
reduce acute care asthma utilization.
WVFH members 2 years of age and older are eligible for the program. Members
are automatically enrolled once they are identified with asthma, but they are able
to opt out if they choose. Care Managers are available by phone.
Member
benefits
and support
The program will provide the following member benefits and support:
• Care managers are available to help support your plan of care by providing
telephonic management. This can help your patients understand the
importance of medication adherence and asthma control
• Your patients will receive asthma educational materials and selfmanagement tools
• Information on smoking cessation with referral to the state Quitline
• Member newsletter with asthma related articles
• Asthma Program information is available via the WVFH website
Provider
benefits
and support
Provider benefits and support include:
• Support from our care managers and other health care staff to ensure that
your patients understand how to best manage their condition and selfevaluate their health status.
• Patient education and assistance with co-existing conditions, smoking
cessation and medication compliance supports optimal self-management.
• Physician Dashboard reports are mailed to the primary care practitioner
(PCP) to assist with optimal medication management.
• Membership in the Asthma Program is voluntary. If at any time your
patients wish to stop participating in the program, they only need to call.
FOR MORE
INFORMATION
For more information or to refer a patient to the Asthma Program, please call
1-855-412-8004.
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4.3 DIABETES PROGRAM
Program
overview
The WVFH Diabetes Program emphasizes education and personal responsibility
for diabetes management to reduce the need for hospitalizations, ER visits and to
prevent diabetic complications. Care Managers are available by phone for
members and physicians.
All adult and pediatric WVFH members with Type 1 or Type 2 diabetes are eligible
for this program. Members are automatically enrolled once we identify them with
diabetes. They are able to opt-out if they choose.
Member
benefits
and support
The program will provide members with the following benefits and support:
• Support from nurses and other health care staff to ensure that your
patients understand how to best manage their condition and evaluate
their health status
• Diabetes educational materials
• Targeted reminders to patients who are due for screenings
• Member newsletter with diabetes related articles
• Diabetic information the WVFH website.
Provider
benefits
and support
Provider benefits and support include:
• Support from our care managers and other health are staff to ensure that
your patients understand how to best manage their condition and
evaluate their health status.
• Diabetic educational reminder materials are mailed to your patients
• Physician Dashboard reports are mailed to the primary care practitioner
(PCP) to assist with optimal management
• Patient education with co-existing conditions, smoking cessation and
glucometer use reduces likelihood of hospital admissions
FOR MORE
INFORMATION
For more information or to refer a patient to the Diabetes Program, please call
1-855-412-8004.
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4.3 CARDIAC PROGRAM
Program
overview
The WVFH Cardiac Program provides patient education and self-empowerment
for medication adherence to reduce the need for hospitalizations and ER visits and
to delay the onset of cardiac complications.
WVFH members, age 21 or older, with a diagnosis of congestive heart failure
(CHF), myocardial infarction (Ml), and coronary artery disease (CAD) are eligible for
the program. Members are automatically enrolled once we identify them with one
of these cardiac conditions.
Membership in the Cardiac Program is voluntary. If at any time your patients wish
to stop participating in the program, they only need to call.
Member
benefits
and support
The program will provide the following member benefits and support:
• Patient education and self-management tools
• Cardiac information
• High-risk cardiac patients with inpatient admissions receive telephonic
case management
• Information on smoking with referral to the state Quitline
• Member newsletter with cardiac related articles
• Cardiac Program information is available via the WVFH website
• Home care and DME needs are coordinated through the WVFH Care
Manager
Provider
benefits
and support
Provider benefits and supports include:
• Support from our care managers and other health care staff to ensure that
your patients understand how to best manage their condition and
evaluate their health status
• Cardiac specific educational materials are mailed to patients
• Patient education for co-existing conditions, smoking cessation,
medication compliance, and weight supports optimal self-management
FOR MORE
INFORMATION
For more information or to refer a patient to the Cardiac Program, please call
1-855-412-8004.
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4.3 CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)
PROGRAM
Program
overview
The WVFH COPD Program emphasizes patient education, self-management, and
medication adherence. The program promotes lifestyle modifications and safety
to reduce inpatient utilization, emergency room visits and preventable flare ups.
WVFH members 21 years of age and older with a diagnosis of COPD are eligible
for this program. Members are automatically enrolled once they are identified
with COPD, but are able to opt-out if they choose.
Membership in the COPD Program is voluntary. If at any time your patients wish to
stop participating in the program, they only need to call.
Member
benefits
and support
The Program will provide the following member benefits and support:
• Care managers are available to support your plan of care. They can provide
telephonic management to help educate your patients about their COPD.
• Your patients will receive COPD educational materials and selfmanagement tools.
• Information on smoking cessation with referral to the state Quitline.
• Member newsletter with COPD related articles.
• COPD program information is available via the WVFH website.
Provider
benefits
and support
Provider benefits and support include:
• Support from nurses and other health care staff to ensure that your
patients understand how to best manage their condition and evaluate
their health status
• Motivate your patients to assume a proactive role in their health
• Provide patient education about comorbid conditions to help reduce
hospitalizations
FOR MORE
INFORMATION
For more information or to refer a patient to the COPD Program, please call
1-855-412-8004.
WEST VIRGINIA FAMILY HEALTH PROVIDER MANUAL | CHAPTER 4.3
7|P a g e
FEBRUARY 2016
4.3 SPECIAL NEEDS CARE MANAGEMENT
Goal of
SNCMU
The goal of the Special Needs Care Management Unit (SNCMU) is to intervene in
medically or socially complex cases that may benefit from increased coordination
of services to optimize health and prevent disease.
Contact
information
A Special Needs Care Manager is available at 1-855-412-8004, Monday through
Friday from 8:30 AM to 4:30 PM, to assist with coordination of the member’s
health care needs.
When calling after hours or on holidays, Member Services is available at
1-855-412-8001.
The responsibilities of the SNCMU include:
SNCMU
responsibilities
• Liaison with various health care practitioners, community social service
agencies, advocacy groups and other agencies that the Medical Assistance
population may interface with;
• Case management of children with medically complex special needs;
• Coordination of services between primary care, specialty, ancillary, and
behavioral health practitioners within and outside the network;
• Facilitation of dispute resolution including informing members of the
complaint, grievance, and appeal mechanism that is available to the
member; and
• Facilitation of members’ access to city, county, and Commonwealth social
agencies for those members with complicated ongoing social service
needs that affect their ability to access and use medical services.
Criteria
for referral
The following problems and/or diagnoses are examples of appropriate referrals to
the Special Needs Care Management Team:
• Children with special health care needs (i.e., Cerebral Palsy)
• HIV/AIDS
• Mental Health or Substance Abuse Issues
• Mental Retardation/Developmental Disabilities
WVFH allows for a standing referral to a specialist for sixty (60) days or to serve as a
primary care practitioner (PCP) in certain pre-authorized situations. The specialist
must be an existing WVFH practitioner, must be agreeable to following WVFH’s
requirements for acting as a PCP, and must receive prior authorization by WVFH’s
Medical Director. Practitioners interested in obtaining more information regarding
this process should contact Provider Servicing at 1-855-412-8002.
WEST VIRGINIA FAMILY HEALTH PROVIDER MANUAL | CHAPTER 4.3
8|P a g e
FEBRUARY 2016
4.3 COMPLEX CASE MANAGEMENT
Program
overview
WVFH provides a Complex Case Management Program for eligible members.
Participation in this program is voluntary.
A Care Manager can help your patient to better understand their health
conditions and benefits and can also help to coordinate health care services by
interacting with providers. A Care Manager can tell your patient about
community organizations and resources that may meet their needs.
Member
eligibility
Eligible members may include:
• Members with multiple medical conditions
• Members with a complex medical history
• Members that need assistance to become more self-reliant in managing
their health care
Referrals
To make a referral, please call: 1-855-412-8004, Option 2. WVFH will review the
request for enrollment and make the final decision for inclusion in the program.
WEST VIRGINIA FAMILY HEALTH PROVIDER MANUAL | CHAPTER 4.3
9|P a g e
DIVA - Telephonic Eligibility and Referral System
If you wish to verify eligibility or if you are a PCP or OB/GYN and wish to issue a referral, begin
by calling the DIVA Eligibility/Referral System at 1-888-907-8002. Available 24/7. You will need
the member’s 8-digit WVFH ID and your 7-digit WVFH practice ID and hospital or specialist from
the Provider directory located at www.wvfh.com. Follow the telephone prompts or refer to the
quick reference guide below. To speak to a Customer Service Representative just press 0.
MAIN MENU
 To verify a member’s coverage, press 1.
 To create a new referral, press 2.
 To review existing referrals, press 3.
TO VERIFY MEMBER COVERAGE - Because of frequent changes in a member’s eligibility, each participating practitioner
is responsible to verify a member’s eligibility with WVFH BEFORE providing services.
 Using telephone keypad, enter member’s 8-digit WVFH ID followed by #. (Press  to start over.)
 To verify coverage or PCP assignment for today’s date of service, press 1.
 To enter a different date, press 2. Enter the 8-digit date of service (format as 11.11.1111).
ADDITIONAL INSTRUCTIONS
 For more information, press 1.
 To have this verification faxed to you, press 2.
 To check a different date, press 3.
 To check a different member, press 4.
 To return to the main menu, press #. If your call is complete, you may hang up now.
TO ENTER A REFERRAL TO A SPECIALIST OR HOSPITAL (PCPs issuing referrals to hospitals and specialists)
Referrals allow the PCP to approve specialty services for members on their panel. OB/GYNs may
only issue referrals to participating hospitals. UM Authorization is still required for certain services.
Specialists and hospitals may only review referrals.
ENTER A REFERRAL

Using your telephone keypad, please enter your 7-digit provider ID. Press  to start over.






Enter member’s 8-digit ID and 7-digit provider ID for the specialist or hospital, then press #.
To create a general referral for 3 visits within the next 90 days, press 1.
To create a referral for 9 visits within the next 90 days for allergy or pain management, press 2.
Enter beginning date for referral (back-date up to 30 days and no more than 90 days into future).
Enter the 8-digit date of service (format as 11.11.1111).
To save this referral press 1. ~If successful entry you will receive the following message: This
referral has been saved. The referral ID number is <XXXXX>.
 To discard it and start over with a new referral, press 2.
ADDITIONAL INSTRUCTIONS
 To hear this authorization again, press 1.
 To enter a new referral for the same PCP press 2.
 To enter a new referral for a different PCP press 3.
 To fax this referral press 4.
TO REVIEW A REFERRAL TO A SPECIALIST OR HOSPITAL
 If you are a PCP, press 1.
 If you are a specialist, press 2.
 Enter your 7-digit provider ID and member’s 8 digit ID number.
 Using your telephone keypad, please enter the 10 digit fax number, including the area code.
Your fax has been submitted. If you do not receive it, call Provider Services M-F 8:30-4:30 at 1-855-412-8002.
HealthCheck Health History Form
0-6 Years
Patient Name: _______________________________________ Date of Birth: _________________ Age: ________
Your Name: _________________________________________ Relationship to child: ________________________
Child’s Health History
Child’s Health History
Pregnancy and Birth
Medical problems during pregnancy? ___________________________
_________________________________________________________
In utero drug exposure? _____________________________________
Where was the child born? ___________________________________
Delivered by:
 Vaginal
 C-section
Why C-section? ____________________________________________
Birth Weight: _____________ Birth Length: _______________
 Full Term (> 37 weeks gestation)
 Preterm (< 36 weeks gestation)
 NICU stay: _________________ weeks
Other problems in the newborn period? _________________________
Medications
Current medications and dose: _______________________________
_________________________________________________________
_________________________________________________________
Vitamins: ________________________________________________
Herbs/home remedies: _____________________________________
Over the counter: __________________________________________
Allergies/reactions to medications or vaccines: _______________
_________________________________________________________
_________________________________________________________
Condition
Mother Father Sibling Grandparent
Asthma




Anemia




Blood disorder




Cancer




Heart disease




Heart attack




High cholesterol




High blood pressure




Stroke




Diabetes




Thyroid disease




Kidney disease








Seizures
Depression/anxiety




Drug and alchol use




Other ___________________________________________________
_________________________________________________________
Other Concerns:
Reviewed by: ______________________________________
Date: _____________________________________________
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Exposure/Habits
Any concerns about lead exposure (old home, plumbing,
peeling paint)?
 Yes  No
Do any household members smoke?
 Yes  No
TV hours per day __________________________________________
Computer hours per day ____________________________________
Video games – hours per day ________________________________
Is violence at home a concern?
 Yes  No
Family Medical History
Do any family members have any of the following conditions?
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Developmental
Do you have concerns about any of the following:
 Problems with sleeping or nightmares
 The way your child uses his/her arms, fingers or legs
 Speech problems
 Bad temper/breath holding/ jealousy
 Nail biting/thumb sucking
 Vision (Are you concerned about your child’s vision?)
 Hearing (Are you concerned about your child’s hearing?)
Dental
 Problems with teeth or gums
 Bad breath
Has your child been seen by a dentist?  Yes  No
If so, date of last exam: _______________________________
Why did he/she see the dentist? ________________________
Water source:  City  Well
H
Infancy and Childhood
Has your child ever been treated for or diagnosed with:
 Asthma or wheezing _______________________________
 Pneumonia ______________________________________
 Lung problems ___________________________________
 Heart murmur ____________________________________
 Anemia _________________________________________
 Recurrent ear infections ____________________________
 Hearing problems _________________________________
 Vision or eye problems _____________________________
 Urinary tract infections _____________________________
 Stomach or digestive problems ______________________
 Seasonal allergies or eczema _______________________
 Seizures ________________________________________
 Broken bone(s) __________________________________
 Learning disability ________________________________
__________________________________________________
 Depression/anxiety _______________________________
 ADD/ADHD______________________________________
 Other chronic medical problems ______________________
__________________________________________________
Has your child ever been hospitalized?
 No  Yes Why? ________________________________
Previous surgeries: __________________________________
Please list any specialists your child is currently seeing and reason:
_________________________________________________________
Nutrition and Feeding
 Has your child had any feeding/dietary problems? ______________
_________________________________________________________
 Unexplained weight gain
 Unexplained weight loss
 Food allergies: _______________________________________
 Participates in WIC
HealthCheck Health History Form
7-20 Years
Patient Name: _________________________________________________ Date of Birth: _________________ Age: ________
Your Name: _______________________________________________ Relationship to child: ____________________________
Child’s Health History
Childhood
Has your child ever been treated for or diagnosed with:
 Asthma or wheezing _____________________________________
 Pneumonia ____________________________________________
 Lung problems _________________________________________
 Heart murmur __________________________________________
 Anemia _______________________________________________
 Recurrent ear infections __________________________________
 Hearing problems _______________________________________
 Vision or eye problems ___________________________________
 Urinary tract infections ___________________________________
 Stomach or digestive problems _____________________________
 Seasonal allergies or eczema _____________________________
 Seizures ______________________________________________
 Broken bone(s) _________________________________________
 Learning disability _______________________________________
_________________________________________________________
 Depression/ anxiety _____________________________________
 ADD/ADHD ___________________________________________
 Other chronic medical problems ____________________________
_________________________________________________________
Has your child ever been hospitalized?
 No  Yes Why? ______________________________________
Previous surgeries: ________________________________________
Please list any specialists your child is currently seeing and reason:
_________________________________________________________
_________________________________________________________
Developmental/Behavior
Do you have concerns about any of the following:
 Problems with sleeping or nightmares
 The way your child uses his/her arms, fingers or legs
 Speech problems
 Bad temper/breath holding/jealousy
 Nail biting/thumb sucking
 Bedwetting (after 6 years)
 Vision (Are you concerned about your child’s vision?)
 Hearing (Are you concerned about your child’s hearing?)
Does your child have problems with:
 School attendance
 Getting along with other children including siblings
 Getting along with parents or other adults
 Threaten to harm self, others or animals
 Sexual acting out
 Destroying property
 Drug use, alcohol use or smoking
Puberty
Concerns about:
 Body changes
 Sexual activity
 Sexually transmitted infection
 Discharge: vaginal or penis
 Contraception
Medications
Current medications and dose: _______________________________
_________________________________________________________
_________________________________________________________
Vitamins: ________________________________________________
Herbs/home remedies: _____________________________________
Over the counter: __________________________________________
Allergies/reactions to medications or vaccines: _______________
_________________________________________________________
_________________________________________________________
Nutrition
 Has your child had any dietary problems? _____________________
_________________________________________________________
 Unexplained weight gain
 Unexplained weight loss
 Food allergies: _________________________________________
Dental
 Problems with teeth or gums
 Bad breath
Has your child been seen by a dentist?
 Yes  No
If so, date of last exam: _____________________________________
Why did he/she see the dentist? ______________________________
Exposure/Habits
Any concerns about lead exposure (old home, plumbing,
peeling paint)?
 Yes  No
Do any household members smoke?
 Yes  No
TV hours per day __________________________________________
Computer hours per day ____________________________________
Video games – hours per day ________________________________
Is violence at home a concern?
 Yes  No
Family Medical History
Do any family members have any of the following conditions?
Condition
Mother Father Sibling Grandparent
Asthma




Anemia




Blood disorder




Cancer




Heart disease




Heart attack




High cholesterol




High blood pressure




Stroke




Diabetes




Thyroid disease




Kidney disease








Seizures
Depression/anxiety




Drug and alchol use




Other ___________________________________________________
_________________________________________________________
Other Concerns:
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For Girls:
Age of first menstrual period? ________________________________
Child’s Health History
WVDHHR/BPH/OMCFH/HC 05-2012
Reviewed by: _________________________________________
Date: ________________________________________________
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Provider Services – Medical Review
West Virginia Medicaid Project
PO Box 2254
Charleston WV 25328-2254
888 483 0793
304 348 3380 Fax
Hysterectomy
Acknowledgment Form
WV Medicaid Program
A Hysterectomy is the surgical removal of the uterus. The procedure renders the individual
permanently and irreversibly sterile (unable to become pregnant).
I certify that the above information has been read and explained to me and I fully understand that
following this surgical procedure I will be permanently incapable of reproducing.
The above information was read and explained to me before the surgery.
__________________________________
Member’s Signature
__________________________________
Member’s ID Number
__________________________________
Date
West Virginia Family Health (WVFH) - Maternity Outcome Authorization Form
*** THIS FORM MUST BE FAXED TO WVFH WITHIN TWO (2) BUSINESS DAYS OF THE MOTHER'S DISCHARGE ***
Fax Number 1-855-888-8252
WVFH Member Number
WVFH Member Date Of Birth
/
* 0 1
/
Member Last Name
Member First Name
M.I.
Hospital
Hospital Provider Number
UR Contact Person
Phone
Fax
-
-
Attending MD (Last name, First name)
-
/
Delivery Information:
/
/
/
Type of Delivery:
Live Birth
Vaginal (650)
Neonatal Death (live birth)
C-Section (669.71 )
Fetal Death:
> 22 weeks gestation (656.40)
< 22 weeks gestation (632)
VBAC (650-primary, 654.21-secondary )
Birth #1
Birth #2
Newborn's Medicaid ID Number
Newborn's Medicaid ID Number
Newborn's Last Name
Newborn's Last Name
Newborn's First Name
M.I.
Date of Birth
/
Newborn's First Name
/
Birth Time
Gender
Actual Discharge Date (for Mom)
Actual Admit Date
Date of Birth
(military time)
M
/
/
/
Birth Time
F
Gender
(military time)
M
Birth Weight
Birth Weight
Apgars
Apgars
Gestational Age
Gravida/Para
M.I.
/
F
Gestational Age
/
Home Health Offered?
Gravida/Para
Y
/
N
/
Home Health Offered?
Baby Admitted to:
Y
/
N
Baby Admitted to:
Newborn Nursery
Newborn Nursery
Special Care Nursery
Special Care Nursery
NICU
NICU
Discharge Status:
to care of Mom (HB )
to Foster Care (FC )
for Adoption (A )
Fetal Death (MFD )
Neonatal Death (MND )
home without baby (NB )
IF ADDITIONAL DAYS FOR MOM OR BABY ARE NEEDED, OR IF MOM DESIRES A POSTPARTUM HOME HEALTH VISIT,
PLEASE CALL THE UM DEPARTMENT FOR AUTHORIZATION AT 1-855-412-8003
DURING NORMAL BUSINESS HOURS. (MONDAY - FRIDAY 8:30 AM - 4:30 PM)
FOR WEST VIRGINIA FAMILY HEALTH USE ONLY
AUTHORIZED LENGTH OF STAY
AUTHORIZATION NUMBER
MEMBERS EFFECTIVE DATE OF COVERAGE
ADMIT TYPE
DISENROLLMENT DATE
MAT
WEST VIRGINIA FAMILY HEALTH
MEDICAID DRUG EXCEPTION FORM
Please complete and fax all requested information below including any progress notes, laboratory test results,
or chart documentation as applicable to West Virginia Family Health Pharmacy Services.
FAX: (855) 430-9849
If needed, you may call to speak to a Pharmacy Services Representative.
PHONE: (855) 412-8005 Monday through Friday 8:30am to 4:30pm
First name:
SECTION A - MEMBER INFORMATION
Last name:
Allergies:
Pharmacy Name:
Drug Name Requested:
Date of Birth:
Member ID:
Type of reaction(s):
SECTION B - PHARMACY INFORMATION
Pharmacy Phone Number:
SECTION C - CLINICAL INFORMATION
Dosage and Frequency:
Quantity:
Length of therapy:
Diagnosis for which drug is being requested:
Date Medication Initiated:
Is the Patient currently receiving requested medication?
Yes 
No 
You must be able to document the therapeutic failure or contraindication to preferred/formulary products for a
request to be approved.
PREFERRED/FORMULARY ALTERNATIVES THAT HAVE BEEN USED BY THE PATIENT
Drug Name/ Strength
Dates Tried:
Reason therapy failed or discontinued
Is member currently or recently hospitalized?
Yes 
No 
Date of Discharge:
Additional Clinical or Supporting Information: Please include office notes, lab data, and other supporting medical
literature.
Prescriber Name (printed):
Office Phone:
SECTION D - PRESCRIBER INFORMATION
Prescriber Specialty:
Contact
Person:
Prescriber Signature:
Extension:
NPI Number:
Office Fax:
Date:
If the request is denied, the prescriber can change the prescription to an appropriate preferred/formulary alternative or with
written member consent file an appeal with West Virginia Family Health.
Revised 9/2014
May Photocopy for Office Use
15
West Virginia Family Health (WVFH) Member Outreach Form T h e i n f o r m a t i o n i n t h i s b o x i s r e q u i r e d . P l e a s e c o m p l e t e a l l l i n e s . Member Name: AGE: WVFH ID #: DOB: Date of Last EPSDT screen (for members <21 years old) Parent/Guardian Name: Relationship: Phone #: ( ) PCP Name Provider ID#: PCP Contact Person: PCP Contact Phone #: Date sent to WVFH: Member is being referred for the following: o
o
o
Over due for EPSDT screen – Last Screen date: _____________ o
Elevated Blood Lead Level Date of last draw: ________________ Result of last draw: ______ Date script was given for Blood Lead Level ____________________________ Notified by mail (attach letter) Notified by phone call on: ________________ o
o
Member Education Regarding Referral Use Behind on these immunizations: _____________________________________________ Chronic no show for appointments or follow up care: (list dates missed) ____________________________________________________________________ Reason for Appointment: _______________________________________________ Referred for services: Services needed: (Be Specific) __________________________________________________________________ Referred to Physician: ________________________ Phone # ___________________ Comments or Addition Information: _____________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ (A WVFH Representative will telephonically contact the member and provide education, assist with scheduling appointments and assist with transportation as appropriate) Mail To: -­‐ or -­‐ Fax To: Care Management (EPSDT) Preventive Health Department West Virginia Family Health Fax: 1-­‐855-­‐430-­‐9847 Four Gateway Center 444 Liberty Avenue Suite 2100 Pittsburgh, Pa 15222-­‐1222 If you have questions concerning the use of this form, call the Preventive Health Department at 1-­‐855-­‐412-­‐8004 Option 3. April 2014
Provider Services – Medical Review
West Virginia Medicaid Project
PO Box 2254
Charleston WV 25328-2254
888 483 0793
304 348 3380 Fax
Physician Certification
For Hysterectomy
This is to certify that:
_____________________________________________________
Member’s Name
_________________________________________
Member’s Medicaid Number
_______________________________________________________________________________________________________________
Member’s Address
I.
Was already sterile before the hysterectomy due to:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
II.
Required a hysterectomy performed under a life-threatening emergency situation in which prior
acknowledgment was not possible. (Describe in detail the nature of the emergency).
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
________________________________
Physician’s Signature
________________________________
Date
Physician Certification
For Pregnancy Term i nati on Form
The Physician Certification for Pregnancy Termination Form must be completed and maintained on file at
the practice location and available for review upon request by BMS and its designee
Please print or type.
Member's Name
Member’s Medicaid Number
Member's Address
I.
Certification of General Medical Necessity (must be certified for all claims).
I,
(attending physician),having discussed this matter with the
patient prior to the service, certify on the basis of my professional judgment, this pregnancy
termination was necessary in light of physical, em otional, psychological, familial or age factors or
a combination thereof) relevant to the well-being of the patient.
II.
Certification of Specific Medical Necessity (only if applicable).
I,
(attending physician).certify that on the basis of my
professional judgment, this pregnancy termination was medically necessary due to one or
more of the following factors. (Check all that apply):
Pregnancy resulting from rape
Endangerment of mother’s life
if the fetus were carried to
full term
Pregnancy resulting from incest
Physician's Signature
Date
PO Box 2254  Charleston, WV 25328-2254  Phone: 888-483-0793  Fax: 304-348-3380
Revised 06/15
WEST VIRGINIA
PRENATAL RISK SCREENING INSTRUMENT
Last Name:
First Name:
MI:
Date of Birth:
/
Street:
State:
City:
Race:
Ethnicity:
No
/
/
Current
Weight (lbs) :
Height
(Ft-inches) :
Medicaid #
Obstetrical History:
Gravida
Para
Term
Oral Health:
Pre
Pregnancy Risk Factors:
Previous Cesarean Section
Low Birth Weight (<2500GM)
Abnormal Amniocentesis
PIH/Preclampsia
Abnormal Genetics Screen
History of PROM
Previous Stillbirth
Abdominal Surgery
Opioid Abuse Treatment
Asst Reproductive Technology
SAB
/
/
/
LMP: (MM/DD/YYYY):
EDC: (MM/DD/YYYY):
Date of Last Delivery:
Blood
Pressure:
Type of Delivery:
1st Trimester
Miscarriage
2nd Trimester
Miscarriage
Preterm Birth
Current Preg. Prior Preg.
Y
N
Y
N
na
na
Fetal Reduction
na
na
Macrosomia
na
na
IUGR
na
na
Oligo/Polyhdramnios
na
na
Gestational Diabetes
na
na
Placental Abruption
na
na
Ectopic Pregnancy
Obesity
Hepatitis B
Hepatitis C
EAB
Live
/
/
/
Abortion
Abortion
Term Birth
Current Preg. Prior Preg.
Y
N
Y
N
Sensitive/Bleeding Gums
Yes
Loose/Broken/Decayed Teeth
Yes
No
Dental visit within the last year
Yes
No
Do you intend to breastfeed?
Yes
No
Are you currently breastfeeding?
Yes
No
Group B Strep
Pyelonephritis
Placental Previa
Cervical Incompetence
Other/Unlisted Risk:Factor:
Bleeding during current pregnancy?
Trimester:
On
Current Preg. Prior Preg. Family Hist. Medical Conditions:
Yes
No
Meds
Y
N
Y
N
Y
N
Multiple Gestation
High Blood Pressure
Fetal Genetic/Structural Abnormalities
Kidney Disease
Psychosocial Risk Factors:
Yes
No
Diabetes
Disabled
Asthma
Unemployed/Inadequate income
Heart Condition
Husband/Partner Employed
Thyroid Disease
Homeless
Environmental Risk Factors:
Yes
Unstable Housing
Lead: House Built before 1978
Education <12 years
Viral: Cats or Birds in Home
Currently in Foster Care
Tobacco: 2nd or 3rd Hand Smoke
Inadequate Transportation
Reasons for Late Entry into Prenatal Care:
Inadequate Social Support
Unplanned Pregnancy
Does not apply
Nutritional Concerns
Insurance Enrollment Delay
Eating Disorder
Unaware of Importance of PNC
Domestic Violence
Couldn't find a health provider
Difficulty with Reading and Understanding
Abortion desired/unsuccessful
Internet Access
Have you ever been a victim of abuse or violence?
Has your partner's anger ever worried or scared you?
Have you ever felt down or hopeless?
Have you lost interest in things you used to do for fun?
Individual NPI#
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
No
No
No
No
No
No
No
Provider Name and Title: (print)
No
Current Preg. Prior Preg.
Y
N
Y
N
1st
2nd
Yes
Family History:
Have either of your parents had a problem with drugs or alcohol?
Has your partner had a problem with drugs or alcohol?
Have you had a problem with drugs or alcohol in the past?
Have you used drugs or alcohol during this pregnancy?
Alternate #:
No Insurance
Hispanic/Latino
Not Hispanic/Latino
(Check all that apply)
Date of 1st Prenatal Visit: (MM/DD/YYYY)
/
Telephone:
Insurance Source:
Health Insurance
Married:
Yes
No
/
County of Residence:
Zip Code:
U.S. Citizen:
Yes
White
Black/African American
Asian
American Indian/Alaska Native
Native Hawaiian/Pacific Islander
Social Security #:
/
3rd
No
No
On
Meds
Clotting Disorder
STD
Seizures
Rh Negative
Other:
No
Yes
Yes
Financial
Child Care Issues
Access to pregnancy testing
Transportation
Other:
Have you ever smoked cigarettes? Yes
No
Do you currently smoke cigarettes? Yes
No
If yes, # of cigarettes per day:
I quit (when):
Does your partner smoke? Yes
No
Provider Telephone #:
Date:
I am interested in further follow-up. I give my consent for necessary referrals to be made. I understand that my participation in any referral services is voluntary and that all
information provided will be held strictly confidential.
Date:
Patient Signature:
Patient Name: (print)
/
6368915
WVDHHR/BPH/OMCFH/DPWH PRSI 04/27/2012
PLEASE COMPLETE AND FAX TO (304) 957-0176
/
WV PRENATAL RISK SCREENING INSTRUMENT INSTRUCTIONS
The Prenatal Risk Screening Instrument (PRSI) is intended to promote early and accurate identification of prenatal risk factors. Prenatal risk screening is
conducted at the first prenatal visit. If the patient answers “Yes” to any pregnancy or medical risk factor, a Maternal Fetal Medicine consultation should be
considered.
General Instructions
Print clearly. Complete the form accurately and completely. When asked to select “Yes” or “No”, choose only one option.
Patient Information
Name (List patient’s Last Name, First Name & Middle Initial)
Date of Birth (List patient’s date of birth as MM/DD/YYYY)
Social Security Number (List patient’s social security number; if patient is undocumented or a non-citizen use 000-00-0000)
Address (Use current address where the patient resides)
County of Residence (List the West Virginia County that patient’s address is located)
Telephone Number (Use a current telephone number & alternate number, if applicable, where patient can be reached)
Race/Ethnicity (Check all that apply)
U.S. Citizen (Choose only one option)
Married (Choose only one option)
Insurance Source (Select type of insurance source that patient currently has; if Medicaid, list Medicaid number; private insurance, list insurance company name,
ex: PEIA, BCBS)
Entry into Prenatal Care
Date of First Prenatal Visit (Enter the date of the patient’s initial medical examination during this pregnancy)
Current Weight (List patient’s current weight in pounds)
Height (List patient’s current height in feet/inches)
Blood Pressure (List patient’s blood pressure reading at time of this visit)
Obstetrical History
Gravida (Enter # of pregnancies in the boxes; include current pregnancy in this number. If Gravida >1, the Para field must be completed.)
Para (This is the # of: Term=Term Deliveries; Pre=Preterm Deliveries; SAB=Spontaneous Abortions; EAB=Elective Terminations; & L=Live Births)
LMP (List date of last menstrual period)
EDC (List estimated date of confinement)
Date of Last Delivery (List patient’s last pregnancy delivery date, if applicable)
Type of Delivery (Select type of delivery patient had from last pregnancy, if applicable)
Oral Health
Select “Yes” or “No”. If patient answers “Yes” to any of the questions, please consider a referral to a dentist or provide patient education.
Breastfeeding
Select “Yes” or “No” to the questions regarding breastfeeding.
Pregnancy Risk Factors
Select “Yes” or “No” to indicate the presence of risk factors in the patient’s current and/or prior pregnancy(ies).
Bleeding During Current Pregnancy
If “Yes”, select the trimester(s) that bleeding occurred. Select “No” if bleeding did not occur.
Family History
Select “Yes” or “No” to indicate the presence of risk factors in the patient’s current and/or prior pregnancy(ies) and/or whether there is a family
history for the selected risk factors.
Medical Conditions
Select “Yes” or “No” to indicate whether the patient currently has the listed medical risk factor and/or is taking medication for the condition.
Psychosocial Risk Factors
Select “Yes” or “No” for each risk factor listed.
Environmental Risk Factors
Indicate by selecting “Yes” or “No” whether the patient has been exposed to listed items in their environment. A patient who lives in a house built before 1978 is at
risk for exposure to lead paint.
Reasons for Late Entry into Prenatal Care
Complete this section only when a patient enters prenatal care in the 2nd or 3rd trimester. Fill in “Yes” for all reasons that apply.
Additional Screening Questions
These questions are used as a screening tool to begin discussion about use of drugs, alcohol, tobacco and/or abuse. Advise the patient that the responses she
provides are confidential and may only be used for her evaluation and treatment. Any patient who answers “Yes” to one or more questions may warrant further
assessment and follow-up.
Provider Information
List name, title, individual NPI# and telephone number of provider completing the PRSI; list date the form was completed.
Consent
Patient’s participation in any referral services is voluntary and her consent must be provided. If patient is interested in further followup/referrals, she must print
name, sign and date the form. If patient is not interested in referral services, please leave this section blank.
Completion
Fax the form to (304) 957-0176. Do not include coversheets. Check to be sure the correct side of the form is transmitted. Fax only one form per patient; do not refax a patient’s form. Duplicate faxes create problems with processing. Authorization for Services
•
•
•
Authorizations are the responsibility of the ordering physician
Reimbursement for services requires that they are billed with valid covered codes included on WVFH’s fee schedule
Call Provider Services at 1-855-412-8002 for further explanation of what services require a referral or
authorization
AUTHORIZATION, REFERRAL, SELF-REFERRAL, SCRIPT GUIDE 6/29/14
This listing of procedures should not be considered all inclusive.
PCP
REFERRAL
ALLERGY VISITS
ANGIOGRAMS
AMBULANCE
BONE DENSITOMETRY
BONE SCAN
CARDIAC/PULMONARY REHAB
CT SCANS
CHEMOTHERAPY (Hospital & Physician Office)
CHIROPRACTIC SERVICES (Benefit limited to
spinal manipulations only – 98940, 98941 & 98942)
COSMETIC PROCEDURES
DIALYSIS
DME/ORTHOTICS/PROSTHETICS/MEDICAL
SUPPLIES:
Covered items under $500 (purchase or rental)
& Items on MA fee schedule
Items over $500.00
Items not on Medical Assistance fee schedule
ELECTIVE ADMISSIONS
EMERGENCY SERVICES (Par and Non-Par)
FAMILY PLANNING (Par and Non-Par)
FETAL NON-STRESS TESTS
HEARING AIDS & EAR MOLDS (members under 21)
HEART CATHETERIZATIONS (Performed in Lab)
HOME HEALTH VISITS/HOSPICE
INPATIENT REHAB
LABORATORY TESTING - Par Laboratory
LABORATORY TESTING - Non-Par Laboratory
MAMMOGRAMS (all types and Par Only)
MENTAL HEALTH/SUBSTANCE ABUSE
MRI/MRA
NERVE CONDUCTION TESTING - Facility
NERVE CONDUCTION TESTING - Physician Office
NON-PAR PROVIDERS
NUCLEAR CARDIOLOGY
NUTRITIONAL EDUCATION
OB/GYN SERVICES (Par Only)
ORTHOPTICS/VISUAL TRAINING
PAIN MANAGEMENT-Consult to pain clinic
PAIN MANAGEMENT-Performed in Physician office or OP
WVFH
AUTH
SELFREFER
SCRIPT
COMMENTS
X
X
X
X
X
X
X
X
Participating chiropractors
permitted to render x-rays
X
X
X
X
X
X
X
X
X
X
X
X
X
Benefit limited to
individuals under 21 years
of age
X
X
X
X
X
Covered by FFS
X
X
X
X
X
X
X
X
X
X
AUTHORIZATION, REFERRAL, SELF-REFERRAL, SCRIPT GUIDE 6/29/14
This listing of procedures should not be considered all inclusive.
PCP
REFERRAL
WVFH
AUTH
SelfReferred
X
PET SCANS
Benefit limited to
individuals under 21 years
of age
X
PRIVATE DUTY NURSING
X
RADIATION - Radiology Services-Standard Plain Film
RESPIRATORY THERAPY SERVICES - Including
Atrial Blood Gases, Pulmonary Function Test, and
Pulse Oximetry
ROUTINE EYE EXAMS (Under the age of 21 only
& services must be rendered by a par provider)
SLEEP STUDY
SPECIALIST OFFICE VISITS (except Ob/Gyn)
SPU &/or SURGICAL Services (except those listed
below)
Abortion, Bariatric Surgery/Stapling,
Blepharoplasty, Breast Reduction, Carpal
Tunnel Surgery, Genital Reconstruction,
Hysterectomy, Panniculectomy, Tubal
Ligations, Removal of Breast Implant,
Rhinoploasty, Spinal Neuro Stimulator
Services, TMJ Surgery, Transplants/Implants,
Varicose Vein
Any Service provided in a Par Lab or Par OP
Facility
THERAPY SERVICES (Physical, Occupational,
Speech) Initial Evaluation
THERAPY SERVICES (Physical, Occupational,
Speech) Ongoing Visits
TOBACCO CESSATION PROGRAM
ULTRASOUND (All types)
URGENT CARE CENTERS
Par
Non-par
WEIGHT MANAGEMENT
COMMENTS
SCRIPT
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Mail to:
West Virginia Family Health
P.O. Box 830499
Birmingham, AL 35283-0499
11928899WV
REFERRAL
FORM
For claims payment purposes
each referral you issue requires a NEW form to
be downloaded and printed.
Just print, complete and mail to the address above.
PRIMARY
PCP Name:
CARE INFORMATION
Automated telephone referrals may be done through
WVFH’s DIVA/EVS line at 1-888-907-8002.
PATIENT INFORMATION
PCP Address:
Patient Name: ________________________
WVFH Member ID#: __ __ __ __ __ __ __ __
PCP Phone:
Diagnosis/Complaint: __________________
PCP Group Provider ID #: __ __ __ __ __ __ __
____________________________________
____________________________________
SPECIALTY PROVIDER OR FACILITY INFORMATION
SPECIALTY PROVIDER - Complete specialist name and provider group ID for services rendered at office site only.
FACILITY PROVIDER -
Complete facility name and facility ID for services rendered at outpatient facility to
allow both facility and physician services to be covered.
REFERRED TO:
Provider Name:
_
Provider Group or Facility ID Number:
Office Visit - 3 Visits/90 Days

Laboratory Testing Performed by a
Participating Lab ONLY Requires a
Script

Laboratory Testing Performed by a NonParticipating Lab Requires an UM
Authorization
Allergy Services - 9 Visits/90 Days
Nerve Conduction Testing - 9 Visits/90
Days
__ __ __ __ __
Pain Management - 9 Visits/90 Days
(Call 1-855-412-8003, M-F 8:30 am – 4:30 pm
to obtain authorization)


The referral must be in WVFH’s claim system at the time the bill is received to be applied to the service rendered.
Payment for referral and precertified services is contingent upon the patient being an effective WVFH member on the date of
service at the time of claim processing.
PCP Signature:
(An unsigned form is invalid.)
Referral Date: ____-____-____ (If referral is not dated, WVFH will date according to receipt at the claim office.)
Created 9/14
Refund Form Instructions for Providers: West Virginia Family Health cannot accept verbal requests to retract claim(s) overpayments. Providers may complete and submit a Refund Form or a letter that contains all of the information requested on this form. This form, together with all supporting materials relevant to the claim(s) reversal request being made including but not limited to EOB from other insurance carriers and your refund check should be mailed to: PNC BANK, c/o GATEWAY HEALTH PAYMENTS/REFUNDS, Lock Box #645171, 500 1st Avenue, Pittsburgh, PA 15219. PLEASE COMPLETE BELOW Date_______________ Group Name_________________________________________ Group Number______________ Address________________________________________________________________ Phone Number ______________ Practitioner Name____________________________________ Individual Provider Number________________________ Vendor Name_______________________________________ Tax Identification Number __________________________ Contact Person at Provider’s Office____________________________________ Phone Number_____________________ E-­‐mail Address______________________________________________________________________________________ Member/Claim Information Name W.V.F.H. ID # DOS Claim Number Refund Amount _________________________ _______________ __________ _____________ ____________ _________________________ _______________ __________ _____________ ____________ _________________________ _______________ __________ _____________ ____________ (Please use a separate sheet for additional Member/Claim Information) Reason for Refund (Please check/mark the box that apply) : o Payment of Outstanding Credit Balance AR o Duplicate Payment o Medicare o Other Insurance Name(s): __________________________ o Provider Billing Error o Unable to Identify Patient o Multiple Payments (If multiple members are affected, check box and attach a copy of your Remit with names highlighted) o Other: _______________________ COMMENT: ____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________ West Virginia Family Health | P.O. Box 22190 | Pittsburgh, PA 15222 | 855-412-8002 | www.wvfh.com
DHS-2510-ENG (11/93)
U.S. Department of Health and Human Services
Public Health Service
INFORMATION
FOR WOMEN
Your Sterilization Operation
NOTICE:
Your decision at any time not to be sterilized will not result in the withdrawal or
withholding of any benefits provided by programs or projects receiving federal
funds.
You will find a consent form at the back of this pamphlet.
This information is available in other forms to people with disabilities by contacting us at
651-296-8517 (voice), toll free at 1-800-657-3659, or through the Minnesota Relay Service at
711 or 1-800-627-3529 (TDD) or 1-877-627-3848 (speech-to-speech relay service).
Why This Pamphlet Is Important to You
Sterilization is an operation that is intended to be
permanent. This pamphlet describes the sterilization
operation for women and its benefits, discomforts,
and risks. Other family planning methods that are
not permanent are also described. You should feel
free to ask your doctor any questions after you have
read the pamphlet completely.
If the Federal government is to pay for your
sterilization, certain conditions must be met.
They are listed on page 8. The purpose of these
conditions is to ensure that you understand
sterilization and that you choose freely to have this
operation.
Both men and women can be sterilized. This
pamphlet is about sterilization operations for
women. (Ask your doctor or clinic for the pamphlet
on sterilization for men.)
Sterilization must be considered permanent. For
most women, once this operation has been done,
it can never be undone. Some doctors try to undo
a sterilization with surgery. This is a difficult and
Making Up Your Mind
1
expensive operation, and often it doesn’t work.
Some people call sterilization “tying the tubes.”
But don’t think the tubes can be easily untied!
They can’t. So it’s not a good idea to think your
sterilization can be undone.
can force you to be sterilized as a condition for
delivering your baby or performing an abortion.
To have this operation paid for with Federal
funds, you must be at least 21 years old. If you are
married, discuss the operation with your husband.
However, his consent is not required if Medicaid
or any Federal government program is going to pay
for your operation. Your consent to sterilization
cannot be obtained while you are in the hospital
for childbirth or abortion, or if you are under the
influence of alcohol or other substances that affect
your state of awareness. You must sign the consent
form at least 30 days before you plan to have the
operation. This is so you will have at least 30 days
to think it over and discuss it with your family and
others. You may change your mind any time before
the operation and cancel your appointment.
Make sure you do not want to bear children under
any circumstances before you decide to be sterilized.
Are you sure you would not want to have children
even if one of your present children died? Or your
husband died? Or you got divorced and remarried?
Be sure of your decision before you decide to be
sterilized. Talk it over with your family or others
you trust.
No one can force you to be sterilized! Don’t let
anyone push you into it. If you do not want to be
sterilized, no one can take away any of your Federal
benefits such as welfare, Social Security, or health
care-including sterilization at a later date. No one
Other Methods of Family Planning
There are many other ways to avoid pregnancy.
Before you decide to be sterilized, think about other
methods of family planning.
pregnancy. It is usually safe. In some women the pill
causes minor side effects such as darkening of the
skin of the face, nausea, spotting, missed periods or
tender breasts. More serious complications which
occur infrequently include depression, increased
tendency for abnormal blood clotting, increased risk
of heart attack and stroke (especially in women over
age 35 -who smoke), and a small increased risk of
liver or gall bladder disease.
Temporary Methods of Family Planning
The following methods of family planning are
temporary. This means that when you or your
partner do not use them you can become pregnant.
Temporary methods of family planning are effective
only if you use them correctly. If you think you
might want to become pregnant later, you should
use a temporary method of family planning
instead of sterilization. Ask your doctor or clinic
for pamphlets and counseling on any of these
temporary methods of family planning.
Intrauterine Device (IUD
(IUD)—A small piece of
plastic is inserted into a woman’s uterus (womb)
by a doctor or family planning clinician. It is 94
percent effective in preventing pregnancy. ICTD
use can cause heavier periods and cramps. A serious
complication in couples who are not mutually
faithful is increased risk of sexually transmitted
infection which can cause infertility.
Birth Control Pill
Pill—A pill a woman takes regularly
which is 97 percent effective in preventing
2
Diaphragm, Cervical Cap, or Contraceptive
Sponge—A rubber cup or sponge a woman places
Sponge
in her vagina over her cervix before intercourse. The
diaphragm or cap must be used with contraceptive
gel or cream for it to be effective. The diaphragm or
cap is 82 percent effective in preventing pregnancy.
The sponge contains a contraceptive already. The
effectiveness rate of the sponge is 82 percent for
women who have not had children and 72 percent
for women who have had children. There is little
risk of serious complications, but minor side effects
such as vaginal and urinary tract infections may
occur. Benefits include some protection against
sexually transmitted diseases.
• charting the menstrual periods;
• charting the woman’s body tempera ture;
• checking the cervical mucus;
• checking the position and texture of the cervix.
Effectiveness requires cooperation between partners.
There is no risk of complications. No drugs or
devices are necessary. Natural family planning
teaches a woman about her own fertility patterns.
Norplant
Norplant—A
set of 6 hormone-containing capsules
that are inserted beneath the skin of the inner upper
arm and can remain effective for 5 years. It is over
99 percent effective in preventing pregnancy. Its
effectiveness is decreased in women who weigh over
150 pounds. Most women using Norplant will have
an abnormal bleeding pattern. Other minor side
effects may occur, such as headache, nervousness,
nausea, dizziness. A health care provider must insert
or remove Norplant in a procedure which lasts
15-20 minutes. Norplant does not protect against
sexually transmitted diseases including HIV/AIDS.
Contraceptive Foam, Cream, Gel, Tablet or Film
(Spermicide)—Spermicidal preparations a woman
places in her vagina each time before intercourse.
They are 79 percent effective in preventing
pregnancy. They occasionally cause minor side
effects such as allergic reactions. Benefits include
some protection against sexually transmitted
diseases.
Sterilization for a Man
Condom, Rubber, Prophylactic—A thin sheath
of rubber the man places over his penis each
time before intercourse. In general use, it is 88
percent effective in preventing pregnancy. There
are no serious side effects. A condom can be used
with contraceptive foam, cream or gel, or with a
diaphragm for extra protection. Condoms give
protection against sexually transmitted diseases
including HIV/AIDS.
A man can be sterilized by an operation called
a vasectomy. This operation is intended to be
permanent. It is simpler, quicker, and safer than
the sterilization operation for a woman, so you and
your partner may decide that it is better for him to
have the sterilization operation. Sterilization does
not offer protection against sexually transmitted
diseases, including HIV/AIDS. (Ask your doctor or
clinic for the pamphlet on sterilization for a man.)
Natural Family Planning
Planning—A type of family
planning in which intercourse is avoided on the
days each month when a woman is likely to get
pregnant. In general use, it is 80 percent effective
in preventing pregnancy. Natural family planning
consists of several methods, all of which require
instruction. Different methods involve some
combination of:
What About Abortion?
Abortion does not prevent pregnancy. It is an
operation to terminate a pregnancy which has
already started.
This pamphlet does not address abortion; it only
addresses ways to avoid pregnancy.
3
When Can a Woman Have a Sterilization Operation?
A sterilization operation can be done at different
times. A talk with your doctor or clinic can help you
decide what might be most suitable for you.
hours after she has signed the consent form, she
does not need to wait 30 days, and the sterilization
may be performed at the same time as the other
surgery. She should be sure that she does not want
to have children again even if the baby does not live
very long after birth.
A woman may choose to have a sterilization
operation at any time in her life. It doesn’t matter
if she is not married or doesn’t have children. It is
up to her. Sterilization done at too young an age
or before a woman has any children may result in
regret later. Circumstances can also change in your
life which might cause you to regret your decision
to be sterilized.
A woman can have a sterilization operation at the
same time she has a baby by cesarean section. A
sterilization operation can be done at the same time
through the same incision, but the woman must
make up her mind at least 30 days before the baby
is due.
A woman can have a sterilization operation right
after having a baby. This means that a woman may
want to be sterilized while she is in the hospital
for the delivery. A woman should think about this
early in her pregnancy because in order for the
sterilization to be paid for with Federal funds she
must sign the consent form at least 30 days before
the baby is due. If the woman delivers prematurely
or has emergency abdominal surgery at least 72
A woman can have a sterilization operation when
she is having another type of surgery if she has
signed the consent form at least 30 days previously.
A woman can have a sterilization operation done at
any other time as well. The operation need not be
done at the time of childbirth, cesarean section or
another surgery.
Facts About the Operation
The surgical method of family planning is called a
tubal sterilization or tubal ligation.
should use some temporary method of family
planning until you have your operation.
In this operation the doctor blocks your two
tubes to prevent the sperm and egg from uniting.
(See figure below.) Menstruation (monthly
period) continues following sterilization. Tubal
sterilization will not cause menopause (change of
life). Sterilization does not offer protection against
sexually transmitted diseases, including HIV/AIDS.
The Anesthetic
With any method of sterilization, you will first be
given an anesthetic (a drug to keep you from feeling
pain during the operation). A medical person who
specializes in anesthesia may do this part of the
operation.
Sometimes the operation is done under “general”
anesthesia. That means you will be asleep during
the operation. The drugs used are a gas which you
inhale and/or a liquid given to you by injection.
Is the Operation Guaranteed to Work?
Tubal sterilization works almost all the time. On
the average only 4 out of every 1,000 women who
have the operation will still get pregnant. Failures
occur when sterilization surgery is performed after
the woman is already pregnant or when there is
incomplete blocking of the woman’s tubes. You
Sometimes the operation is done under “local”
anesthesia or “spinal” anesthesia. That means you
are awake.
4
A local anesthetic is given by injection into the skin.
It makes your skin numb.
operation. Serious problems rarely happen. Most of
the time serious problems can be treated and cured
by the doctor without further surgery; however, an
operation may be necessary to correct some of these
problems.
A spinal anesthetic is given by injection low in the
spine. This type of injection makes you feel numb
from the waist down
Some of the medical problems you could have
during or after a sterilization operation include:
With local or spinal anesthesia, you may also be
given pills or another injection to help you relax.
1. You may bleed from the incision on your skin or
in your vagina.
You should have a chance to discuss and participate
in the decision regarding your type of anesthesia
before your operation.
2. You may bleed inside your abdomen. (Another
operation may be necessary to stop the bleeding.)
3. You may get an infection on or near the stitches
or inside your abdomen.
TUBE CUT AND TIED
4. The operation may not make you sterile.
The operation cannot be guaranteed 100%
to make you sterile. On the average 4 out of
1,000 women get pregnant after the operation.
When this happens there is a possibility that
the pregnancy may be in the tube. This would
require immediate medical or surgical care.
OVARY
UTERUS ( Womb)
VAGINA
Benefits of Tubal Sterilization
The benefits of tubal sterilization are:
5. As in other operations, the anesthetic drug used
to put you to sleep or to make the operation
painless may cause problems. You may
vomit while under anesthesia and additional
complications may result. As with all surgery,
complications sometimes lead to death.
• You never have to use a temporary method of
family planning again (such as the pill or the
diaphragm).
• You don’t have to worry about getting pregnant.
Discomforts and Risks
6. You may have damage to your internal organs,
such as your bowel or bladder. More medical
care or another operation may be necessary to
repair the damage.
No matter which type of operation you have,
you can expect to feel pain and soreness in your
abdomen for a few days. You can take medicine to
help relieve the discomfort.
7. Some women have reported irregular periods,
increased cramping or changes in their periods
after sterilization.
If you had general anesthesia, you may have a sore
throat for a day or two from the tube used to keep
your airway open while you were asleep. This goes
away quickly and is not serious. Spinal anesthesia
may give some persons a temporary headache.
Go back to your doctor at once if you get a
fever or severe pain in your abdomen soon after
surgery. Either of these could be signs that you
have an infection.
Sterilization operations rave some risks, including a
very small risk of death. This is true, of any type of
5
Four Types of Tubal Sterilization
The operation you have depends on your health
and your doctor. Talk to him or her about which
operation you will have.
1.
2.
3.
4.
incision. It is a thin metal tube with a light on it
which allows the doctor to see your tubes, and
through which the doctor can insert the operating
instruments. Your tubes are sealed by the use of
electric current, bands, or clips. Some doctors make
a second small incision near the pubic hair line to
insert one of the operating instruments.
Laparotomy, Mini-laparotomy
Laparoscopy
Postpartum tubal sterilization
Vaginal tubal sterilization
After the gas in your abdomen is released, the
incision is closed.
Laparotomy, Mini-Laparotomy
In both of these operations, the doctor makes
an incision (cut) in the lower portion of your
abdomen. The difference between the two is the
length of the incision and the extensiveness of the
surgery. In a mini-laparotomy the incision is very
short (one or two inches) and leaves only a small
scar. In a laparotomy it is much longer (three to five
inches) and leaves a longer scar. Ask your doctor
which method he or she uses.
The operation, including the anesthesia, takes about
30 minutes. You will probably stay in the hospital
less than 24 hours and be back to normal in two or
three days. Because of the gas, you may feel a pain
in your neck or shoulders, and you may feel bloated
after the surgery. This goes away after a day or two.
Postpartum Tubal Ligation
This operation is done in the hospital shortly after
a woman has a baby. The doctor makes a small
incision below your navel. The doctor then closes
off a section of each tube using surgical threads.
After the tubes are tied, a small section between
the ties is removed. The incision below your navel
is stitched closed. The operation, including the
anesthesia, usually takes about 30 minutes. Having
the operation may make your hospital stay a day or
two longer. How fast you get better will depend on
how you feel after having the baby.
Through the incision on the abdomen, the doctor
can reach both tubes, one at a time. The doctor can
either remove a section and then use surgical thread
to tie the tubes shut or seal them with electric
current, bands or clips. After the tubes are sealed,
the incision on your abdomen is stitched closed.
The operation, including the anesthesia, takes
about 30 minutes. With a minilaparotomy, you
will probably stay in the hospital less than 24 hours
and be back to normal in two or three days. With a
laparotomy, you will probably be in the hospital two
or more days, and it may be two weeks before you
feel back to normal.
Vaginal Tubal Ligation
In this operation, the doctor makes a small incision
far back in the vagina. Through this, the doctor
finds your tubes, then closes them off with electric
current, bands, or clips, or by removing a small
section and closing the ends with surgical threads.
After the tubes are sealed, the incision in your
vagina is stitched closed.
Laparoscopy
Using a special needle, the doctor inflates your
abdomen with gas which pushes your intestines
away from your uterus and tubes.
The doctor then makes a small incision about onehalf inch long near your navel. A “laparoscope,”
or special instrument, is inserted through this
Sometimes the doctor will use a metal tube with a
light (called a culdoscope) to find your tubes.
6
The operation, including the anesthesia, usually
takes about 30 minutes. Your stay in the hospital
will probably be less than 24 hours. You should be
back to normal in two or three days. After this type
of operation, you should not have intercourse for
three to four weeks so the vagina can heal.
Summary
What About Hysterectomy?
If You Have Questions
Hysterectomy is the removal of the uterus. A
hysterectomy should be done only when there
is a disease of the woman’s uterus or some other
problem that is appropriately treated by removal.
Hysterectomy should never be performed for
sterilization alone.
If there is anything that is not clear to you, or
anything you are worried about, it is important
that you ask these questions. All of your questions
should be answered to your satisfaction before the
operation.
If you are sure you do not want to bear children and
you want to become permanently sterile, then tubal
sterilization is a safe, effective option. It requires a
short stay in the hospital, and problems are rare.
REMEMBER
A hysterectomy is a much more serious operation
than a tubal sterilization. A hysterectomy takes
much longer to do, and the woman is in the
hospital longer. There are more discomforts, and
there is a greater chance of serious complications as
a result of hysterectomy. For these reasons, neither
Medicaid nor any other Federal program will pay
for a hysterectomy if you are having it solely to
avoid bearing children.
You may change your mind at any time before
the operation. Make sure you do not wish to bear
children under any circumstances before you decide
to be sterilized.
RULES FOR STERILIZATION OPERATIONS FUNDED BY THE FEDERAL GOVERNMENT
• You must be at least 21 years old.
• You must wait at least 30 days to have the operation after you sign the consent form except in
instances of premature delivery or emergency abdominal surgery that take place at least 72 hours after
consent is obtained..
• Your consent to sterilization cannot be obtained while you are in the shopital for chldbirth or
abortion, or under the influence of alcohol or other substances that affect your state of awareness.
• You may, if you choose, bring someone with you when you sign the consent form.
• Your consent is effective for 180 days from the date you sign the consent form.
Your consent to sterilization must be documented by signing a consent form identical or
similar to the sample attached to this pamphle
This pamphlet has been prepared by the U.S. Department of Health and Human Services. It describes the sterilization
procedures used in current medical practice. The pamphlet contains a sample of the consent form which, unless another form
is approved by DHHS, must be used for sterilizations paid for with Federal funds. Both the pamphlet and consent form comply
with regulations: 42 CFR 50.201 et seq. and 42 CFR Part 441, Subpart F.
Issued, 1978; Revised, 1991.
‘U.S. Government Printing Office: 1993- 357-505 DHS-2510 (11-93)
7
CONSENT FORM
NOTICE:
Your decision at any time not to be sterilized will not result in the withdrawal or withholding of any
benefits provided by programs or projects receiving federal funds.
 Statement of Person Obtaining Consent 
 Consent to Sterilization 
I have asked for and received information about sterilization
from _________________________.When I first asked for
(doctor or clinic)
the information, I was told that the decision to be sterilized is
completely up to me. I was told that I could decide not to be
sterilized. If I decide not to be sterilized, my decision will not affect
my right to future care or treatment. I will not lose any help or
benefits from programs receiving Federal funds, such as A.F.D.C. or
Medicaid that I am now getting or for which I may become eligible.
I understand that the sterilization must be considered
permanent and not reversible. I have decided that I do
not want to become pregnant, bear children or father
children.
I was told about those temporary methods of birth control that
are available and could be provided to me which will allow me to
bear or father a child in the future. I have rejected these alternatives
and chosen to be sterilized.
I understand that I will be sterilized by an operation known as
a ____________________. The discomforts, risks and benefits
associated with the operation have been explained to me. All my
questions have been answered to my satisfaction.
I understand that the operation will not be done until at least
thirty days after I sign this form. I understand that I can change
my mind at any time and that my decision at any time not to
be sterilized will not result in the withholding of any benefits or
medical services provided by federally funded programs.
I am at least 21 years of age and was born on ______________.
Month/Day/Year
I, ___________________________________, hereby consent
of my own free will to be sterilized by_______________________
(doctor)
by a method called __________________________________.
My consent expires 180 days from the date of my signature below.
I also consent to the release of this form and other medical
records about the operation to:
• Representatives of the Department of Health, Education, and
Welfare or
• Employees of programs or projects funded by that Department
but only for determining if Federal laws were observed.
I have received a copy of this form.
__________________________________Date:_____________
Signature
Month/Day/Year
You are requested to supply the following information, but it is
not required:
Race and ethnicity designation (please check)
 American Indian

or Alaska Native
Asian or Pacific Islander
 Black (not of Hispanic origin)
 Hispanic
 White (not of Hispanic origin)
 Interpreter’s Statement 
If an interpreter is provided to assist the individual to be
sterilized:
I have translated the information and advice presented orally to
the individual to be sterilized by the person obtaining this consent.
I have also read him/her the consent form in _______________
language and explained its contents to him/her. To the best of my
knowledge and belief he/she understood this explanation.
_________________________________________________
Interpreter
Date
1. Patient
2. Physician
Before _____________________________________ signed
Name of individual
the consent form, I explained to him/her the nature of the sterilization
operation __________________________, the fact that it is intended
to be a final and irreversible procedure and the discomforts, risks and
benefits associated with it.
I counseled the individual to be sterilized that alternative methods
of birth control are available which are temporary. I explained that
sterilization is different because it is permanent.
I informed the individual to be sterilized that his/her consent can be
withdrawn at any time and that he/she will not lose any health services
or any benefits provided by Federal funds.
To the best of my knowledge and belief the individual to be
sterilized is at least 21 years old and appears mentally competent. He/
She knowingly and voluntarily requested to be sterilized and appears to
understand the nature and consequence of the procedure.
__________________________________________________
Signature of person obtaining consent
Date
__________________________________________________
Facility
__________________________________________________
Address
 Physician’s Statement 
Shortly before I performed a sterilization operation upon
_____________________________ on _________________,
Name of individual to be sterilized
Date of sterilization operation
I explained to him/her the nature of the sterilization operation
_______________________________, the fact that it is intended
specify type of operation
to be a final and irreversible procedure and the discomforts, risks and
benefits associated with it.
I counseled the individual to be sterilized that alternative methods
of birth control are available which are temporary. I explained that
sterilization is different because it is permanent.
I informed the individual to be sterilized that his/her consent can be
withdrawn at any time and that he/she will not lose any health services
or benefits provided by Federal funds.
To the best of my knowledge and belief the individual to be
sterilized is at least 21 years old and appears mentally competent. He/
She knowingly and voluntarily requested to be sterilized and appeared
to understand the nature and consequences of the procedure.
Instructions for use of alternative final paragraphs: use the first
paragraph below except in the case of premature delivery or emergency
abdominal surgery where the sterilization is performed less than 30
days after the date of the individual’s signature on the consent form. In
those cases, the second paragraph below must be used. Cross out the
paragraph which is not used.
(1) At least thirty days have passed between the date of the
individual’s signature on this consent form and the date the
sterilization was performed.
(2) This sterilization was performed less than 30 days but more
than 72 hours after the date of the individual’s signature on this
consent form because of the following circumstances (check applicable
box and fill in information requested):
 Premature delivery
Individual’s expected date of delivery: ________________________
 Emergency abdominal surgery
(Describe):_____________________________________________
___________________________________________________
Physician
3. State Agency, Program or Project
Date