FALL 2013
PROVIDER
WORKSHOPS
AGENDA
Medicaid Expansion
 Policy Updates to BMS Provider Manual
 Claim and Coding Updates
 Program Updates
 Provider Enrollment and Screening
 Audits
 Medicaid Partner Information
 Automated Health Services
 Molina’s New Version of Health PAS
 Q&A’s, ICD-10 Survey & Workshop Evaluation

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MEDICAID EXPANSION

On May 2, 2013, Governor Earl Ray Tomblin
announced the expansion of the WV Medicaid
Program.

Two major components:
1.
2.
Coverage to individuals aged 19 to 64 and former
foster children making up to 138% of the Federal
Poverty Level (FPL).
Expansion of Managed Care to include behavioral
health, personal care and children’s dental services.
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IMPACT OF MEDICAID EXPANSION

Medicaid expansion will provide insurance coverage to
more than 90,000 West Virginians.

Ends the disincentive to current Medicaid enrollees
from working. Impoverished families can work to the
middle class and no longer fear losing insurance
coverage.
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MEDICAID EXPANSION

West Virginia Medicaid currently serves:
 Pregnant
Women
 Children
 Very
Low Income Families
 Aged/Blind/Disabled
 Medically Needy Populations

On October 1, 2013, WV Medicaid will begin
enrolling the expanded population for coverage
effective January 1, 2014:

Adults between 19 and 64
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PERSONAL RESPONSIBILITY



West Virginia will implement co-payments for
members enrolled in managed care beginning January
1, 2014.
Medicaid members not enrolled in managed care will
not have co-payments.
Exempt from co-pays are:



Pregnant Women; Children under 18; Individuals in Nursing
Homes, receiving Hospice, or covered through the Breast &
Cervical Cancer Treatment Program
Emergency Services
Family Planning Services
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MEDICAID EXPANSION
In our current system we only cover non-disabled
adults up to 17% of FPL.
 Today, a family of four can only earn approximately
$3,700 a year. Starting on October 1 that same
family can earn approximately $32,000 a year.

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MANAGED CARE
Managed care is being expanded to include
behavioral health, personal care, and children’s
dental.
 Both the newly eligible (expansion) individuals and
current Medicaid members enrolled in managed
care will receive most of their Medicaid services
through managed care.

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UPDATES TO BMS PROVIDER MANUAL
Chapter 517 - Personal Care
Public Comment period extended to 9/4/13
 Proposed changes include:
 Fingerprint-based Criminal Background Checks
 Prior authorization of all hours

 60
hours/240 units
 Submit Pre-Admissions Screening (PAS) tool and a
physician certification form to APS HealthCare for
approval.
 Prior authorization for 61 hours/244 units to 210
hours/840 units will remain the same
 Authorizations will be a maximum of 12 months.
 Will be phased in for members who are receiving
Personal Care services prior to implementation date
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CLAIM AND CODING UPDATES

Reminder: Effective January 1, 2014, claim
payment via Electronic Funds Transfer (EFT) is
required by Federal law



EFT form(s) on Molina’s website
Contact Molina for assistance
2012 ADA Claim Form
Molina assessing date when system can accept 2012
ADA form
 Providers will need to include the following items on the
2012 ADA Claim Form for payment consideration:

 Place of Service
 Quantity or number of units
 Diagnosis codes and diagnosis-to-code
 Multiple tooth surfaces
pointers
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CLAIM AND CODING UPDATES

RENDERING PROVIDER INFORMATION REQUIRED
EFFECTIVE JANUARY 1, 2014


REFERRING PROVIDER INFORMATION REQUIRED –
TARGET DATE 1ST QTR 2014


Field 24J on CMS 1500 form will be required for each line item billed
 Enter NPI number of rendering provider for service billed on that line
 Line items without rendering provider information will be rejected
Claim Fields 17, 17a and 17b on CMS 1500 form required for referring provider
information
 Applies to specific types of service/providers, such as radiology and lab
 Current plan for claim processing:
 Process claims without required referring provider information with
warning message for limited period of time
 At end of limited timeframe, activate edit to reject claims without
required referring provider information
Watch BMS and Molina websites, provider newsletter for
additional information in future
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CLAIM AND CODING UPDATES
NATIONAL CORRECT CODING INITIATIVE (NCCI)




Mandated by the Affordable Care Act of 2010 to incorporate NCCI into
Medicaid claims processing
 Procedure to Procedure (PTP) Edits
 Medically Unlikely Edits
Applies to CMS 1500 and outpatient hospital claims
WV Medicaid implemented NCCI edits in summer 2012
Quarterly updates
 Approximately 300,000 new same day surgery edits in October 2013


Activated in Medicare NCCI edits in July 2013
Appeals
 Appeals for PTP edits must be directed to CMS
 CMS permits BMS to review appeals for MUEs
 MUE Appeals should be sent to Molina
For more information on Medicaid NCCI, go to
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/ByTopics/Data-and-Systems/National-Correct-Coding-Initiative.html
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CLAIM AND CODING UPDATES
ICD-10




Providers, Payers & Vendors must be compliant October 1,
2014!
Per Centers for Medicare and Medicaid Services, if non-compliant
then:
 Claims may not be paid
 Face possible sanctions and/or penalties from Federal Office of
E-Health Standards and Services (OESS) for non-compliance with
HIPAA
BMS workgroup currently assessing system, developing policy
remediation plan, etc.
Code mapping began August 2013 and must be completed by
November 2013.
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CLAIM AND CODING UPDATES
ICD-10 cont’d.

BMS now has ICD10 webpage on Molina’s website

Link on Molina website home page

ICD-10 Webpage includes

WV Medicaid’s ICD-9 to ICD-10 transition

Frequently asked questions

ICD-10 countdown calendar

Links to helpful resources such as webinars, CMS ICD-10 website at
http://www.cms.gov/Medicare/Coding/ICD10/

Email address for questions to WV Medicaid ICD-10 workgroup
(ICD10@wv.gov)

Check BMS webpage and newsletters in future for additional information

Looking for volunteers when ready to test
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PROGRAM UPDATES
ENHANCED PAYMENTS FOR PRIMARY CARE PROVIDERS

The Affordable Care Act (ACA) requires that Medicaid reimburse eligible
primary care providers at parity with Medicare rates in calendar years 2013
and 2014 for certain E&M and vaccination codes.

In order to receive the enhanced rate, eligible physicians and advanced
practice registered nurses (APRNs) must complete a Self-Attestation Form.
Physician Assistants (PAs) automatically qualify if their supervising physician
qualifies and self-attests.

A provider must self-attest that he/she has a specialty or subspecialty
designation of family medicine, general internal medicine, pediatric
medicine, or one of the subspecialties outlined in the Provider’s Guide to
Enhanced Primary Care Payments in West Virginia.

The Provider’s Guide, the 2013 enhance primary care and vaccine
administration fee schedules, self-attestation forms and other guidelines
can be found at http://www.dhhr.wv.gov/bms.
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PROGRAM UPDATES
ENHANCED PAYMENTS FOR PRIMARY CARE
PROVIDERS cont’d.





Approximately 844 providers are currently enrolled
Enhanced payments began on July 12, 2013 for claims
received on and after that date
Retroactive payments back to January 1, 2013, for
enrolled providers will begin soon
Providers can self attest until December 31, 2013, for
enhanced payments for claims with dates of service in
2013
Providers must self- attest in January 2014 to be eligible
for enhanced payments for that calendar year
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PROGRAM UPDATES
TAKE ME HOME WV

Program to move eligible participants from long-term care
setting to home or community-based setting


There are 112 active participants in the program, of which:




began accepting referrals on February 1, 2013
4 are pending eligibility determination
13 have been transitioned into the community
95 are still in the process of developing a transition plan and/or looking
for suitable housing
For more information, call Take Me Home, WV’s office staff at
(304) 356-4926
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PROGRAM UPDATES
HEALTH HOMES FOR MEMBERS WITH CHRONIC
CONDITION

Program is intended to improve the health of Medicaid
members who may need a variety of services to address
primary and acute care, behavioral health care, and long-term
care services.





BMS has been working with stakeholders across the state
To be eligible, Medicaid member must have Bipolar Disorder and be at risk for,
or have, Hepatitis B or C.
Beginning in 6 counties: Cabell, Kanawha, Mercer, Putnam, Raleigh, Wayne
State Plan Amendment (SPA) to be submitted
Six defined health home services






Comprehensive Care Management
Care Coordination
Health Promotion
Comprehensive Transitional Care
Individual and Family Support Services
Referral to Community and Social Support Services
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PROGRAM UPDATES
WV Clearance for Access: Registries and Employment
Screening (WV CARES)
 WV CARES is WV’s grant-funded program under the Affordable
Care Act’s National Background Check Program
 WV is one of 24 State Medicaid Agencies participating in
national program at this time
 Centralized process for fitness determination of potential
employee in long term care setting
 BMS is currently reviewing WV specific web-based screens for




Registry Database Check
State Criminal History Check
Federal Criminal History Check
Will pilot with a few long-term care providers by end of year.
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PROVIDER ENROLLMENT AND SCREENING

Provider enrollment and screening requirements
mandated by ACA

CMS continues to provide guidance to states




Guidance remains pending on Criminal Background Check and
Fingerprinting
Re-validation of providers began in June 2013 for
physicians directly enrolled with Medicaid.
The second phase began earlier this month for
approximately 1000 provider groups
Recent changes


New deadline for re-validation of all WV Medicaid providers
is December 31, 2014.
Anesthesiologist Assistants will not be eligible for
enrollment at this time
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PROVIDER ENROLLMENT AND SCREENING





Providers will receive re-validation notice 1-2 weeks
prior to case number letter
Letter with case number (online PEAP access code)
mailed at least 15 days prior to re-validation start date
Provider has total of 60 calendar days from start date to
re-enroll
30 days after re-validation start date, providers will
receive reminder letter that re-validation must be
completed within the next 30 days
45 days after re-validation start date, providers will
receive reminder that if re-validation is not completed
within next 15 days BMS may place provider on pay hold
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AUDITS
WV PAYMENT ERROR RATE MEASUREMENT
(PERM) 2013
 PERM 2013 Letters were mailed beginning last month
 WV Medicaid PERM Contact:
Scott Winterfeld, Office of Quality and Program Integrity
Telephone: 304-558-1700 or
Email: Scott.E.Winterfeld@wv.gov
RECOVERY AUDIT CONTRACTOR (RAC)
 RAC Vendor is HMS
 First RAC letters to be mailed by October 1, 2013
 Physicians providing pulmonary services
MEDICAID INTEGRITY GROUP (MIG)
 Collaborative effort between CMS and BMS
 First MIG Letters will be mailed to Hospice Providers
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WV MEDICAID PARTNER INFORMATION

WV Bureau for Medical Services


Website at ww.dhhr.wv.gov/bms
BMS Relationships
Molina – Fiscal Agent (FA) – claims processing, provider
enrollment
www.wvmmis.com
 APS – Utilization Management Contractor (UMC) – prior
authorization, case management
www.apshealthcare.com
 HMS – Recovery Audit Contractor (RAC) & Third Party
Liability (TPL)
www.wvrecovery.com

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