WellCare Provider Training
MLTSS 2014
Topics For MLTSS Provider Training
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Sussex
What is Managed Long Term Services and Support
Services under MLTSS
How to qualify for MLTSS
Member Eligibility
Timely Claims Submission
Claims Submission Requirements/Paper Claims
Electronic Claims Submissions/Prompt Payment
Coordination of Benefits/Hold Harmless Dual Eligible
Credentialing
Claims Appeals/Appeals/Grievances
Nursing Facilities/Assisted Living
Prior Authorization
HIPPA Electronic Transactions and Code Sets
Authorization Required for Long Term Care Services
Critical Incident Reporting-MCO requirements
Resources
Warren
Morris
Union
Hunterdon
Somerset
Middlesex
Mercer
Monmouth
Ocean
Burlington
Salem
Atlantic
Cumberland
What is Managed Long Term Services and Support
Managed Long Term Services and Supports (MLTSS) refers to the delivery of long-term services and supports through New
Jersey Medicaid's NJ FamilyCare managed care program. MLTSS is designed to expand home and community-based
services, promote community inclusion and ensure quality and efficiency.
Principles for Managed Long Term Services:
MLTSS overall goal is to provide quality long-term services and supports to individuals of all ages in the most integrated
setting appropriate to their needs.
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Home and Community-Based Services is the preferred service delivery method for people receiving Managed Long Term
Services and Supports (MLTSS).
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Person-centered service options should be available so that individuals of all ages who use MLTSS are enabled to live in the
community, in their own homes if possible;
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Criteria for community living should include: privacy; autonomy; respect; personal preference; cultural differences; dignity;
safety; choice and control within the residential setting; integration with the greater community; independent advocacy when
appropriate; and personal control over moving to, remaining in or leaving the setting; and
Consumer Choice selecting providers and living settings is the priority if MLTSS:
• People of all ages have the right to choose and, if they wish, direct their care plan;
• MLTSS works with individuals to ensure that quality of life is as important as quality of care.
• MLTSS will work to maintain or improve the health and functional state of seniors and people with disabilities.
Services under MLTSS includes:
Personal Care
Respite
Care Management
Home and Vehicle Modifications
Home Delivered Meals
Personal Emergency Response Systems
Mental Health and Addiction Services
Assisted Living
Community Residential Services
Nursing Home Care
Behavioral Health
participants in the Medicaid waiver programs listed below will be automatically enrolled in the Managed Long Term Services
and Supports (MLTSS) program through their current Medicaid managed care organization (MCO), also known as a
health plan:
Global Options for Long-Term Care (GO); AIDS Community Care Alternatives Program (ACCAP); Community Resources for
People with Disabilities (CRPD); or, Traumatic Brain Injury (TBI) Waiver
How to qualify for MLTSS
Global Options for Long-Term Care (GO); AIDS Community Care Alternatives Program (ACCAP); Community
Resources for People with Disabilities (CRPD); or, Traumatic Brain Injury (TBI) Waiver are automatically
enrolled on July 1st 2014
A person also can qualify for Managed Long Term Services and Supports (MLTSS) by meeting these established
Medicaid requirements:
Financial Requirements - These include monthly income, as well as total liquid assets. For more detailed information
on Medicaid financial eligibility, click here.
Clinical Requirements - A person meets the qualifications for nursing home level of care, which means that the
person requires assistance with activities of daily living such as bathing, toileting and mobility.
Age and/or Disability Requirements - These involve age requirements whereby one must be 65 years or older; and/or
disability requirements whereby one must be under 65 years of age and determined to be blind or disabled by the
Social Security Administration or the State of New Jersey.
Member Eligibility
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A member’s eligibility status can change at any time. Therefore, all providers should consider requesting and
copying a member’s identification card, along with additional proof of identification such as a photo ID, and
filing them in the patient’s medical record.
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Providers may do one of the following to verify eligibility:
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Access the secure, online Provider Portal of the WellCare website at www.wellcare.com
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Access WellCare’s interactive voice response (IVR) system; and/or contact the WellCare Provider Service
Department.
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You will need your Provider ID number to access member eligibility through the avenues listed above.
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Molina Medicaid/Family Care Solutions at 800-776-6334 (you must have a Medicaid/Family Care provider
number to use this provider line).
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Medicaid/Family Care FFS Services Enrolled Providers can also visit NJMMIS website at www.NJMMIS.com
and select link on the left side of the page (contact Webmaster) once on the webpage complete request for
username and password and access eMEVS ( the electronic Medicaid/Family Care Eligibility Verification
System) or call 800-776-6334.
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REVS- You must be a Medicaid/Family Care Provider to have access to REVS TEL# 800-676-6562 the
advantage of using REVS is that you can also confirm if a member has Medciare Parts A and B and MCO.
Timely Claims Submission
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Unless otherwise stated in the Provider Participation Agreement (Agreement), provider must submit claims (initial,
corrected and voided) within six (6) months or 180 days from the Medicaid or primary insurance payment date,
whichever is later) from the date of service. Unless prohibited by federal law or CMS, WellCare may deny payment
for any claims that fail to meet WellCare’s submission requirements for Clean Claims or that are received after the
time limit in the Agreement for filing Clean Claims. MCO will adjudicate MLTSS claims within 15 days of clean
claim submission
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If the beneficiary is dually eligible; Medicare must be billed prior to Medicaid/Family Care if the service is covered
by Medicare. Medicare balances may be billed to the Medicaid/Family Care MCO if the Medicare Benefit is
exhausted.
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If the beneficiary is not enrolled in a MCO, or the beneficiary’s Medicaid/Family Care eligibility lapsed and service
is a Medicaid/Family Care billable service the beneficairy may be covered by Medicaid/Family Care FFS
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REMEMBER: Medicaid/Family Care is the payer or last resort
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The following items can be accepted as proof that a claim was submitted timely:
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A clearinghouse electronic acknowledgement indicating claim was electronically accepted by WellCare; and
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A provider’s electronic submission sheet with all the following identifiers, including patient name, provider name,
date of service to match Explanation of Benefits (EOB)/claim(s) in question, prior submission bill dates; and
WellCare product name or line of business.
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The following items are not acceptable as evidence of timely submission:
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Strategic National Implementation Process (SNIP) Rejection Letter; and
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A copy of the Provider’s billing screen. (Continue on next page)
Electronic Claims Submissions
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WellCare accepts electronic claims submission through Electronic Data Interchange (EDI) as its preferred
method of claims submission. All files submitted to WellCare must be in the ANSI ASC X12N format, version
5010. For more information on EDI implementation with WellCare, refer to the Wellcare Companion Guides
which may be found on WellCare’s website.
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Because most clearinghouses can exchange data with one another, providers should work with their existing
clearinghouse, or a WellCare contracted clearinghouse, to establish EDI with WellCare. For a list of WellCare
contracted clearinghouse(s),for information on the unique WellCare Payer Identification (Payer ID) numbers
used to identify WellCare on electronic claims submissions, or to contact WellCare’s EDI team at:
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EDI-Master@wellcare.com
Paper Claims Submissions Cont’d
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The information must be aligned within the data fields and must be:
Typed;
In black ink;
Large, dark font such as, PICA, ARIAL 10-, 11-or 12-point type; and
In capital letters.
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The typed information must not have:
Broken characters;
Script, italics or stylized font;
Red ink;
Mini font; or
Dot matrix font.
MLTSS time frames for claims processing
WellCare is required to adjudicate (pay or deny) claims (for MLTSS members) for MLTSS
services such as: assisted living providers, nursing facilities, special care nursing facilities,
CRS providers, adult/pediatric medical day care providers, PCA and participant directed Vendor
Fiscal/Employer Agent Financial Management Services (VF/EA FMS) claims within the following
timeframes:
1. HIPAA compliant electronically submitted clean claims shall be processed within fifteen (15)
calendar days of receipt;
2. Manually submitted clean claims shall be processed within thirty (30) calendar days of receipt;
and
3. All claims shall be processed within forty-five (45) calendar days of receipt.
Coordination of Benefits (COB)
WellCare shall coordinate payment for Covered Services in accordance with the terms of a member’s benefit
plan, applicable state and federal laws and CMS guidance. Providers shall bill primary insurers for items and
services they provide to a member before they submit claims for the same items or services to WellCare. Any
balance due after receipt of payment from the primary payer should be submitted to WellCare for consideration
and the claim must include information verifying the payment amount received from the primary plan as well as
a copy of the Explanation of Benefits (EOB). WellCare may recoup payments for items or services provided to a
member where other insurers are determined to be responsible for such items and services to the extent permitted
by applicable laws. Providers shall follow WellCare policies and procedures regarding subrogation activity.
Balance Billing
Providers shall accept payment from WellCare for Covered Services provided to WellCare members in accordance
with the reimbursement terms outlined in the Agreement. Payment made to providers constitutes payment in full by
WellCare for covered benefits, with the exception of member expenses. For Covered Services, providers shall not
balance bill members any amount in excess of the contracted amount in the Agreement. An adjustment in payment
as a result of WellCare’s claims policies and/or procedures does not indicate that the service provided is a noncovered service, and members are to be held harmless for Covered Services. For more information on balance
billing, refer to the Provider Manual.
Hold Members Harmless
Those dual eligible members whose Medicare Part A and B member expenses are identified and paid for at the
amounts provided for by DMAHS (Medicaid) shall not be billed for such Medicare Part A and B member expenses,
regardless of whether the amount a provider receives is less than the allowed Medicare amount or provider charges
are reduced due to limitations on additional reimbursement provided by DMAHS. Providers shall accept WellCare’s
payment as payment in full or will bill New Jersey Medicaid if WellCare has not assumed the Agency’s financial
responsibility under an agreement between WellCare and the Agency. For more information on holding harmless
dual eligible members, refer to Medicaid Provider General Manual.
Credentialing Process Highlights
Please take note of the following credentialing process highlights:
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Primary source verifications are obtained in accordance with the state and federal regulatory agencies, accreditation,
and WellCare policy and procedure requirements and include a query to the National Practitioner Data Bank
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Physicians, allied health professionals, and ancillary facilities/health care delivery organizations are required
to be credentialed in order to be network providers of services to WellCare members.
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Satisfactory site inspection evaluations are required to be performed in accordance with state, federal, state and
accreditation requirements.
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WellCare will complete credentialing activities and notify providers within 90 days of receiving a completed
application. The notification to the provider will inform them as to whether they are credentialed, whether
additional time to complete the credentialing process is needed, or that additional providers are not needed at the
time. When additional information is needed t o complete a provider application, WellCare will make the request
from the provider as soon as possible, and no later than 90 days from the receipt of the application. WellCare will
also communicate with providers within these timeframes throughout the provider re-credentialing process.
Claims Appeals
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Provider Claim appeals must be submitted within 90 days of the most recent adverse determination on a claim or
claim appeal. (see provider manual) During all stage of the appeal process or Fair Hearing services will continue if all
the requirements below apply.
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The appeal is filed on time
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The appeal involves a course of treatment that was authorized
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The services were ordered by an authorized network provider
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The written request to continue services is received within 10 days if the date of initial denial letter ( this only applies
to Medicaid/Family Care Fair Hearings) Mail or fax medical appeals with supporting documentation to:
WellCare Health Plans, Inc.
Fax 1-866-201-0657
Attn: Appeals Department
PO Box 313683
Tampa, FL 33631-3368
A beneficiary or provider on behalf of a beneficiary (with beneficiary written consent) can request a Fair Hearing at
any time during the appeals process. The Medicaid/Family Care Fair Hearing Dept. can be reached at: 609-5882655 or 609-588-2656, or via mail or fax to Department of Human Services Medicaid/Family Care Fair Hearing
Dept. 7 Quakerbridge Rd. Mercerville NJ, 08619 Fax# 609-588-7343
Grievances
Member grievances may be filed verbally by contacting Customer Service or submitted via fax or mail.
Providers may also file a grievance on behalf of the member with the member’s written consent.
Mail or fax member grievances to:
WellCare Health Plans, Inc.
Fax 1-866-388-1769
Attn: Grievance Department
PO Box 31384 Tampa, FL 33631-3384
NF, SCNF
MLTSS Any Willing Provider status for NF, SCNF, AL and CRS will be for a two year period from the date that the service comes into MLTSS,
dependent upon available appropriation in each Fiscal Year. For NF, SCNF, AL and CRS that would mean that Any Willing Provider status
expires on June 30, 2016.
Nursing Facility Level of Care (NF LOC)--The designation given to individuals who meet clinical eligibility for MLTSS services. This is assessed
using the NJ Choice Assessment System and findings are validated by OCCO, in accordance with N.J.A.C. 8:85.
Nursing Facility Services(NF) – shall be a covered benefit for Medicaid/NJ FamilyCare A, and the MCO shall be financially responsible for all
nursing facility services for NJ FamilyCare A enrollees from the date the enrollee enters the nursing facility to the date of discharge. Special
Care Nursing Facilities (SCNF) residents currently receiving NJ FamilyCare through Fee-for-Service will convert to managed care on July
1, 2016.
Short term nursing facility stays are available for MLTSS Members receiving HCBS who require temporary placement in a nursing facility due to
temporary illness, serious injury, wound care, or the absence of the primary caregiver and there is a reasonable expectation that the member
will be discharged back to the community within 180 days.
If, prior to the end of the 180 day period (post admission date) it is determined that the member will not be discharged from the nursing facility,
the member shall be determined as custodial. The member is automatically converted to custodial status in the nursing facility if the member
is in the nursing facility beyond 180 days.
Current custodial nursing home residents on Medicaid will remain in a fee-for-service environment. Medicaid beneficiaries living in Special Care
Nursing Facilities (SCNFs) as of July 1, 2014 will remain in the fee-for-service environment for two years.
Any individual who is newly eligible for Medicaid and living in a nursing home after July 1, 2014 will have his/her care managed by a NJ
FamilyCare MCO through the MLTSS program. Individuals who enter a SCNF after July 1, 2014 will have their acute and primary health
care services and their nursing home care managed by a NJ FamilyCare MCO through the MLTSS program
OCCO is responsible for issuing the final approval or denial letter to the Member.
In the event the Member does not meet NF LOC OCCO will explain to the Member the reason(s) for denial, provide counseling on alternative
HCBS and issue a determination letter which shall include the Member’s right to appeal and how to apply for a Medicaid fair hearing.
AL / AFC
MLTSS Members residing in an Assisted Living (AL) or in an Adult Family Care (AFC) setting may have a cost
share as calculated by the County Welfare Agency and are responsible to pay the provider of services the cost
share. This is in addition to the Room and Board charge established by the state.
MLTSS Members living in Assisted Living (AL) or in an Adult Family Care (AFC) setting, whose income is only
derived from Supplemental Security Income (SSI), will not have a cost share. They will be required to pay the
Room and Board charge established by the state
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Assisted Living: For individuals who are placed in an assisted living residence the Care Manager shall discuss
room and board payments and any potential patient pay liability the Member may incur. Since New Jersey
Medicaid does not cover room and board in a community alternative residential setting, this must be paid by the
Member or other source (such as the Member’s family) directly to the facility. The State shall notify the
Contractor annually of the room and board amount which shall be collected from the resident by the provider. In
addition, the Care Manager shall discuss any patient payment liability for cost of care with the Member. The
patient liability for cost of care is the portion of the cost of care that ALR, CPCH or AFC residents must pay
based on their available income as calculated by the CWA. The State shall notify the Contractor of any
applicable patient payment liability via the 834 eligibility/enrollment file. The Contractor shall delegate
collection of both the room and board and patient payment liability for the cost of care to the provider. The
Contractor shall pay the facility net of the applicable patient liability amount.
Prior Authorization
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MLTSS Prior authorization guidelines to note are:
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Prior authorization decisions for non-emergency services shall be made within 10 days. With complete medical
information Wellcare responds to more than 90% of requests within three business days.
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Within 72 hours of the request, you may log into the website www.wellcare.com for update.
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Prior authorization Denials and limitations must be provided in writing in accordance with the Health Claims
Authorization Processing and Payment Act, P.L. 2005, c.352.
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The prior authorization request should include the diagnosis to be treated and the CPT code describing the
anticipated procedure. If the procedure performed and billed is different from that on the request, but within the same
family of services, a revised authorization is not required.
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An authorization may be given for a series of visits or services related to an episode of care. The authorization
request should outline the plan of care including the frequency and total number of visits requested and t he expected
duration of care.
AUTHORIZATION IS REQUIRED FOR LONG TERM CARE SERVICES
BELOW
Adult Companion Services
Adult Day Health Care
Assisted Living Services
PCA
Pediatric Medical Day Care
CSR
Chore Services
Consumable Medical Supplies
Behavioral Management ( TBI)
Environmental Accessibility Adaptation Services
Family Training Services
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AUTHORIZATION IS REQUIRED FOR LONG TERM CARE SERVICES
BELOW
Homemaker Services
Personal Emergency Response Systems
Respite Care Services
Occupational Therapy
Physical Therapy
Respiratory Therapy
Speech Therapy
Nursing Facility
Assisted Living
Behavioral Health
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Critical Incident Reporting - MCO Requirements
In all MLTSS provider contracts, the Contractor shall require full adherence to the mandatory training and reporting
requirements applicable to Adult Protective Services, office of Institutionalized Elderly, Department of Children and
Families and the Division of Disability Services including but not limited to:
1.N.J.A.C. 8:39-9.4
2.N.J.A.C. 8:36-5.10(A)
3.N.J.A.C. 8:43F-3.3
4.N.J.A.C. 8:43J-3.4
5.N.J.S.A. 52:27D-409
6.N.J.A.C. 8:57
Critical incidents shall include but not be limited to the following incidents
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Unexpected death of a member
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Missing person or unable to contact
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Suspected or evidenced physical or mental abuse (including seclusion and restraints, both physical and
chemical)
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Theft with law enforcement involvement
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Law enforcement contact
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Severe injury or fall resulting in the need of medical treatment
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Medical or psychiatric emergency, including suicide attempt
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Medication error
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Inappropriate or unprofessional conduct by a provider involving the member
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Sexual abuse and/or suspected sexual abuse; and abuse and neglect, including self-neglect, and/or suspected
abuse and neglect
Timeframes for incident reporting
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Contracted MLTSS providers and their staff are required to report, respond to and document critical incidents as
specified by the contractor as follows:
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The maximum timeframe for reporting an incident to WellCare shall be 24 hours, the report might be
submitted verbally, in which case the agency/person/entity making the initial report shall submit a follow-up
written report within 48 hours
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Suspected abuse, neglect, and exploitation must be reported immediately
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WellCare is required to report to DMAHS any death and any incident that could significantly impact
the health or safety of a member within 24 hours of detection or notification
4.
Timeframe for submitting reports shall be as soon as possible, may be based on the severity of the incident
(see # 2,3) but shall not exceed more than 30 calendar days from the day of the incident
CIR and MLTSS Self-Direction
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Consider whether incidents involving members who self direct are tagged and tracked separate from the
traditional systems
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Definitions of critical incidents may need to differ for individuals who are self directing and those in the
traditional agency model
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Important to determine whether reported incident has a direct correlation to the fact that the individual was self
directing and make sure appropriate staff are apprised of this
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Ensuring critical incident reporting is challenging when services are self directed and provided in the members
home or family home, additional considerations include:
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Relying on redundant systems such as grievance/complaint reporting to identify incidents
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Sensitizing care managers/support brokers on how to elicit serious risk issues when visiting with
members/representatives/family
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Providing hotlines for members to call to report problems
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Analyzing incident data related to self direction to detect trends
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Direct service workers and providers of goods and services become mandatory reporters
RESOURCES
Forms and Documents: newjersey.wellcare.com/provider/forms
Quick Reference Quick Reference Guides: newjersey.wellcare.com/provider/resources
Clinical Practice Guidelines: www.wellcare.com/provider/CPGs
Clinical Coverage Guidelines: www.wellcare.com/provider/CCGs
WellCare Companion Guide: newjersey.wellcare.com/provider/claims_updates
Provider Training: newjersey.wellcare.com/Provider/ProviderTraining
EDI team: EDI-Master@wellcare.com